Neck:GeneralHistory

Thepharynxelongatesat5weeksandtheesophaguselongateslater.Afterthe
diaphragmhasdescended,thesethreestructuresseparatetheheadofthe
developingembryofromtherelativelylargeheart.By7weeks,aneckisvisible
(Fig.11).Theunpairedfloorisofendodermaloriginandproducesthetongue,
thyroidgland,larynx,andtrachea.

W4W54archesstartdeveloping&markedexternallybythefourectodermal
branchialorpharyngealcleftsoneachside.Atthesametime,thepharyngeal
pouchesdevelopinternally.Thebridgesbetweenthearchesarethebranchial
membranes,orclosingplates,whichareformedbytheectodermandendoderm
(Figs.12,13).

Allpharyngealgroovesandmembranesdisappearexceptthefirst.Cleft:remains
astheexternalauditorycanal(externalauditorymeatus).Membraneremainsas
thetympanicmembrane(eardrum).

Arch1:mandibular:musclesofmastication,theupperandlowerjaws,andthe
cheekandlowereyelids.V3/facialartery.

Arch2Hyoid:muscleoffacialexpressionandforthestyloidprocess,stylohyoid
muscle,stylohyoidligament,partofthehyoidbone,thestapesandstapedius
muscle,andtheposteriorbellyofthedigastricmuscle.VII/externalcarotiartery.

Arch3
Theonlymusclethoughttobederivedfromthethird(thyrohyoidorglossopharyngeal)
pharyngealarchisthestylopharyngeus.Itisinnervatedbytheglossopharyngealnerve.
Thearteryisthecommoncarotid.
Thefourthpharyngealarchisunnamed.Itisresponsiblefortheembryogenesisofthe
cricothyroidmuscleofthelarynx.Itsnerveisthesuperiorlaryngealbranchofthevagus
nerve.
Thesixtharchfuseswiththefourthfortheformationofthelaryngealcartilages,
thyroidcartilage,andperhapstheaorticarch,rightsubclavianartery,pulmonaryarteries,
andductusarteriosus.Mesodermofthesixtharchisresponsiblefortheembryogenesisof
thepharyngealconstrictors,pharyngealmuscles,andthelaryngealmuscles.Itsnerveis
therecurrentbranchofthevagusnerve.
Thepharyngealpouches:
Thefirstpharyngealpouchisresponsiblefortheembryogenesisoftheeustachian
tube,tympaniccavity,mastoidantrum(about9thmonthofgestation),and
mastoidaircells(about2yearsofage).
Smallbenigngrowthscalled

cholesteatoma2intheformofthickeningsoftheendodermalliningofthemiddleear
developandaresaidtocommonlycausehearinglosses.Whiletheiroriginisnotfully
understood,itisbelievedthattheyformnormallyinallembryos,butoccasionallysome
persistandproliferatetoformthesegrowths.
Thesecondpharyngealpouchproducesthepalatinetonsilsandthetonsillarfossa.
Note:Apersistingsecondplateopeningcanappearasabranchialcleftsinus,notoriously
openintothetonsillarfossa.
Thethirdpharyngealpouch:thedorsalpartisresponsibleforthegenesisofthelower
parathyroids(parathyroidsIII);theventralpartforthethymus.Intheadultpharynx,the
piriformrecessisthesiteofthethirdpouch.
Thefourthpharyngealpouch:thedorsalpartisresponsibleforthegenesisoftheupper
parathyroids(parathyroidsIV);theventralpartmaybeinvolvedwithasmallamountof
thymictissueandwiththeultimobranchialbody.
Forallpracticalpurposes,thefifthpharyngealpouch,likethefifthpharyngealarch,
doesnotexist.
CongenitalAnomalies
Fistulas,externalandinternalsinuses,andcystsaretheresultofobliterationof
pharyngealcleftsandpouches.Thymicandparathyroiddeficiencies(e.g.,DiGeorge
syndrome)aresecondarytopartialortotalagenesisoftheparathyroidandthymus
Page11of203
glands.
Neckhygromasarecongenitalmalformationsofthelymphaticsystemoftheneck.
GidvaniandBhowmick3indicatedthatcystichygromasarecommoncongenitalneck
masses,tendtodevelopintheleftposteriortriangle,andappearearlyinlife.Theauthors
reportedthecaseofaposteriorcervicalmidlinecystichygroma.
Remember
Mostpharyngealfistulasandcystsoriginatefromthesecondpharyngealpouchand
cleft.
Fistulasofthesecondpouchopenattheloweronethirdofthemedialborderofthe
sternocleidomastoid(SCM)muscle.
Anomaliesofthefirstcleftarerelatedtothefacialnerve.
Apharyngealsinusorfistulatypicallytravelsfromthepharyngealwall,betweenthe
internalandexternalcarotidarteries,toreachtheskin.In1993,MillerandCohn4
presentedthe31streportofafourthbranchialpouchsinus.
SurgicalAnatomy
SurfaceAnatomy
Landmarks
Themostprominentlandmarksofthesurfaceanatomyoftheneck,especiallyinmales,
areasfollows:
Thesternocleidomastoidmuscleseparatestheanteriorpartoftheneck(anterior
triangle)fromtheposteriorpartoftheneck(posteriortriangle).

Inmaleswithwelldevelopedmusculature,thelateralportionofthetrapeziusmuscle
producesmuchofthefullnessofthegentlecurvethatjoinsthelateralposteriorpartof
theneckwiththeshoulderregion.Theanteriortuberosityofthetransverseprocessofthe
sixthcervicalvertebra(carotidtubercleofChassaignac)islocatedatthemedialborderof
thesternocleidomastoidandatthelevelofthecricoidcartilage.Pressureatthispointwill
compressthecommoncarotidartery.
Inthemidline,fromabovedownward,thefollowinglandmarksarenoted:
Themostprominentmidlinefeatureandthemostreadilypalpatedisthethyroid
cartilage,theAdamsapple,whichisespeciallyprominentinpostpubertalmales.Itis
locatedbetweenthethirdandfifthcervicalvertebrae.Thebifurcationofthecommon
carotidarteryislocatedonthehorizontalplaneatthislevel.Variationsinthesiteof
divisionofthecarotidarterywillalwaysbelocatedabovethispoint.
Thebodyofthehyoidbonecanbepalpatedatabout1.5cmabovethethyroidcartilage
atthelevelofthethirdcervicalvertebra.(Note:Atthemidpointofalinebetweenthe
mastoidprocessandthethyroidprominence,thegreaterhornofthehyoidbonecanbe
palpatedlaterally.)
Thearchofthecricoidcartilageispalpablejustinferiortothethyroidcartilage.The
cricoidcartilageformstheonlycompletecartilaginousringaroundtheairway,something
thatisnotobservedwiththeothercartilagesoftherespiratorysystem.
Thecricoidcartilageislocatedatthelevelofthesixthcervicalvertebra.
Ahorizontalplaneapproximatelyatthejunctionofthesixthandseventhcervical
vertebraecanbeassociatedwiththe
followinganatomicentities(Figs.14,15,16,and17):pharyngoesophagealjunction
laryngotrachealjunction
Page12of203
inferiorthyroidartery(whichisventraltothemiddlecervicalganglion),andthen(in
order),thecarotidsheath,andtheomohyoidmuscle
entranceoftheinferiorlaryngealnerve(recurrentnerve)intothelarynx
entranceofthevertebralarteryintothetransverseforamenofthesixthcervicalvertebra
and,slightlymoreinferiorly,thestellateganglion
thyroidisthmusandthegreatestheightofthethoracicduct,whicharelocatedatthe
leveloftheseventhcervicalvertebra
FIG.14.
Thethirdcervicalvertebraisatthelevelofthehyoidbone;thefourthandfifthcervical
vertebraeareatthelevelofthethyroidcartilage.(ModifiedfromBrantiganOC.Clinical
Anatomy.NewYork:McGrawHill,1963;withpermission.)
FIG.15.
Page13of203
Sixthcervicalvertebra.(ModifiedfromBrantiganOC.ClinicalAnatomy.NewYork:
McGrawHill,1963;withpermission.)
FIG.16.
Page14of203

Seventhcervicalvertebra.(ModifiedfromBrantiganOC.ClinicalAnatomy.New
York:McGrawHill,1963;withpermission.)
FIG.17.
Diagrammaticcrosssectionthroughtheneckbelowthehyoidboneshowingthelayersof
thedeepcervicalfasciaandthestructuresthattheyenvelop.(ModifiedfromSkandalakis
JE,GraySW,SkandalakisLJ.Surgicalanatomyoftheoesophagus.In:JamiesonGG
(ed).SurgeryoftheOesophagus.Edinburgh:ChurchillLivingstone,1988;with
permission.)
Page15of203
SurgicalApplications
Theconsistencyofcervicalskinchangeswithage.Hyperextensionoftheneckwillgive
abetterappreciationofthetopographyoftheunderlyingstructuresinrelationtotheskin.
Thesurgeonselectstheproperincisionanditsplacementinrelationtotheunderlying
pathology.Theorientationoftheconnectivetissuesofthedermiscreateslinesoftension
intheskin,knownasthelinesofLanger,whichareassociatedwithskincreasesofthe
body.Generallyspeaking,thetransverseincisioniscosmeticallysuperiortothevertical,
sincecrossingthenormalskinlineswillproduceamoreprominentscar.
However,theverticallinesproduceexcellentexposureforsurgeryofthearteries.Most
ofthecommonlyusedincisionsintheneckarepresentedinFigures18and19.
Combinationsofverticalandtransverseincisionscanbeused,ifnecessary.Remember,a
superiorlybasedapronflapshouldbeusedforneckdissection.Closetheedgesofthe
dividedplatysmamusclecarefully,andreapproximatethemarginsoftheskinincision
meticulouslytolessenthelikelihoodofunsightlyscarringfromtensionupontheskin.
FIG.18.
Properplacementofincisionsintheneckparallelingthenormallinesandcreasesofthe
skin.A,Excisionofcongenitalsinus:
partialmobilizationhereandlowersegmentatB1.B,Excisionofcarotidtumoror
branchialcleftcyst.C,Diverticulumofesophagus.D,Scalenotomyorphrenicnerve
interruption.E,Drainageofsubmentalabscess.F,Excisionofthyroglossalcystorsinus.
G,Cricothyreotomy.H,Tracheotomy.I,Thyroidectomy.J,Drainageofcervicalabscess
atangleofjaw.K,Exposureofinternalorexternalcarotidarteries.L,Exposureof
commoncarotidartery.M,Exposureofbrachialplexusorsubclavianartery.(Modified
fromAnsonBJ,McVayCB.SurgicalAnatomy(5thed).Philadelphia,Saunders,1971;
withpermission.)
FIG.19.
Page16of203
Selectedincisionsusedforclassicradicalneckdissection.A,Attie.B,Eckersand
Byer.C,MacFee.D,Morestin.E,Conley.F,LatyshevskyandFreund.G,Martin.H,Z.I,
Barbosa.(ModifiedfromStrongEW.Radicalneckdissection.InNyhusLM,BakerRJ
(eds).MasteryofSurgery,2ndEd.Boston:Little,Brown,1992;withpermission.)

RoonandChristensen5subdividedtheareasoftheneckintothreeregionswithrespect
toinjuries:High(abovetheangleofthemandible)
Middle(betweentheangleandthebottomofthecricoidcartilage)
Page17of203
Low(belowthecricoidcartilage)
SurgeonscontinuetouseRoonandChristensensclassification,buttheynowreferto
zones(Fig.110):ZoneIistheareaRoonandChristensencalledlow;ZoneII,middle;
ZoneIII,high.
FIG.110.
Zonesoftheneck.ThejunctionofzonesIandIIisvariouslydescribedasbeingatthe
cricoidcartilageoratthetopoftheclavicles.TheimportantimplicationofazoneIinjury
isthegreaterpotentialforintrathoracicgreatvesselinjury.(ModifiedfromJurkovichGJ.
Definitivecarephase:neckinjuries.InGreenfieldLJ(ed).Surgery:ScientificPrinciples
andPractice(2nded).Philadelphia:LippincottRaven,1997,pp.309317;with
permission.)
Inthesamestudycitedabove,RoonandChristensenstatedcorrectly,fromananatomic
standpoint,thateitherhighorlowinjuriescaninvolvevesselswhereproximalanddistal
controlisdifficult.Theyadvisedimmediateexploration.
RodenandPomerantz6alsoadvisedearlyoperation(neckexploration)forpenetrating
woundsoftheneck.However,Atteberryetal.7foundphysicalexaminationalonetobe
safeandaccurateforevaluationofvascularpenetratinginjuriesin
zoneIIoftheneck.
However,Biffletal.8statedthatselectivemanagementofpenetratingneckinjuriesis
safeanddoesnotrequireroutinediagnostictestingforasymptomaticpatientswith
injuriesinzonesIIandIII.
WequotefromBumpousetal.9onpenetratinginjuriesofthevisceralcompartmentof
theneck:
ZoneIIoftheanteriorneckwasthemostcommonlyinjuredarea,withthetrachea(69%),
esophagus(38%),andlarynx(31%)themostcommonlyinjuredstructures.Although
31%underwentangiograms,only13%showedvascularinjuries.Eightyonepercentof
thepatientshadinjuriesinvolvingmorethan1majorstructureoftheneck.Neck
explorationwasperformedin81%ofthepatientsandtracheostomiesin75%aswellas
repairofthetrachea(50%),larynx(31%),andesophagus(38%).Thereissignificant
mortalityassociatedwiththeseinjuries...andmanyofthepatientshavelongterm
sequelaesuchasdysphagia,hoarseness,andprolongedtracheostomy.
Fortheevaluationofpenetratingneckinjuries,Demetriadesetal.10concludedthat
physicalexaminationandcolorflow
Page18of203
Dopplerimagingarethediagnostictoolsofchoiceforthephysician.Theypresented
analgorithmfortheevaluationoftheseinjuries(Fig.111).
FIG.111.

Algorithmforevaluationofpenetratingneckinjuries.(FromDemetriadesD,Theodorou
D,CornwellE,BerneTV,AsensioJ,BelzbergH,VelmahosG,WeaverF,YellinA.
Evaluationofpenetratinginjuriesoftheneck:prospectivestudyof223patients.WorldJ
Surg1997;21:4148;withpermission.)
BrittandCole11recommendaparadigmforpenetratingneckinjuries(Fig.112).FIG.1
12.
Page19of203
Penetratingneckinjuriesmanagementguideline.GSW,gunshotwound;SW,stab
wound;HVI,highvelocityinjury;*,controversialapproach.(FromBrittLD,ColeFJ.
Alternativesurgeryintraumamanagement.ArchSurg1998,133:11771181;with
permission.)
TopographicAnatomyoftheNeck
Thetopographyofthenecklendsitselftodescriptionbyusingaseriesofnatural
triangularareas,beginningwiththedivisionoftheneckintoanteriorandposterior
cervicaltriangles,andthenbydivisionoftheseintosmallertriangularregions.
TheAnteriorCervicalTriangle
BOUNDARIES
Theboundariesare:
Lateral:sternocleidomastoidmuscle
Superior:inferiorborderofthemandibleMedial:anteriormidlineoftheneck
Thislargetrianglemaybesubdividedintofourmoretriangles:thesubmandibular,
carotid,muscular,andsubmental(Fig.113).FIG.113.
Page20of203
Theanteriortriangleoftheneckisdividedintofoursmallertrianglesbythedigastric
andomohyoidmuscles.SCM,sternocleidomastoidmuscle.(ModifiedfromSkandalakis
JE,GraySW,RoweJSJr.Surgicalanatomyofthesubmandibulartriangle.AmSurg
1979;45:590596;withpermission.)
SUBMANDIBULARTRIANGLE
Thesubmandibulartriangleisdemarcatedbytheinferiorborderofthemandibleabove
andtheanteriorandposteriorbelliesofthedigastricmusclebelow.Sarikciogluetal.12
reportedananomalousdigastricmusclewiththreeaccessorybelliesandone
fibrousband(Fig.114).FIG.114.
Page21of203
Schematicdrawingofananatomicanomaly.1,anteriorbellyofdigastricmuscle;2,
posteriorbellyofdigastricmuscle;3,accessorybelly;4,fibrousband.(Modifiedfrom
SarikciogluL,DemirS,OguzN,SindelM.Anomalousdigastricmusclewiththree
accessorybelliesandonefibrousband.SurgRadiolAnat1998;20:453454;with
permission.)
Thelargeststructureinthetriangle,andthemostfrequentobjectofthesurgeons
attention,isthesubmandibularsalivarygland.Neartheendofthesixthweek(slightly

laterthantheparotidgland),itdevelopsfromtheoralectoderm.Itformsasasolid
primordium,becomingcanalizedlater.
Severalvessels,nerves,andmusclesalsoarefoundinthetriangle.Forthesurgeon,the
contentsofthetrianglearebestdescribedinfourlayers,orsurgicalplanes,startingfrom
theskin.Itmustbenotedthatsevereinflammationofthesubmandibularglandcan
destroyalltracesofnormalanatomy.Insuchinstances,identifyingandsparingthe
essentialnervesbecomesagreatchallenge.
FirstSurgicalPlane:TheRoofoftheSubmandibularTriangle
Theroofofthesubmandibulartriangleiscomposedofskin,superficialfasciaenclosing
theplatysmamuscleandfat,andtheunderlyingmandibularandcervicalbranchesofthe
facialnerve(VII)(Fig.115).Themandibularandcervicalbranchesofthefacialnerve
arisefromthecervicofacialdivisionofthefacialnerve.This,thelowerdivisionofthe
facialnerve,passeslateralto
theretromandibular(posteriorfacial)veinwithinthesubstanceoftheparotidglandin
morethan90%ofcases;13inothers,itpassesmedialtothevein.Alinedrawnfromthe
intertragicnotchoftheear,intersectingthemidpointofalinebetweentheangleofthe
mandibleandthelowestpartoftheear,willlieclosetothepositionofthecervicofacial
divisionofthefacialnerve.
FIG.115.
Page22of203
Thefirstsurgicalplaneofthesubmandibulartriangle.Theplatysmaliesoverthe
mandibularandcervicalbranchesofthefacialnerve.(ModifiedfromSkandalakisJE,
GraySW,RoweJSJr.Surgicalanatomyofthesubmandibulartriangle.AmSurg
1979;45:590596;withpermission.)
Remember
Theskinshouldbeincised4to5cmbelowthemandibularangle.
Theplatysmaandfatcomposethesuperficialfascia.
Themandibular(ormarginalmandibular)branchofthefacialnerve(VII)liesjust
belowtheangle,superficialtothefacialartery.Savaryetal.14afterstudying10fresh
cadaversand1embalmedcadaver,foundseveralmarginalbranches,particularlythe
intermediateramus,whichcanformaneuralplexusaroundthefacialartery.Basaret
al.15reportedthatthe
Page23of203
marginalmandibularbranchofthefacialnervewassinglein14facialhalves,
consistedoftwomajorbranchesin24facialhalves,andhadmultiplemajorbranchesin2
halves.
CervicofacialDivisionoftheFacialNerve.Thenomenclatureandtopographyofthe
branchesofthefacialnerveareconfusingandvariable.Themandibular(marginal
mandibular)nerveisusuallythefirstbranchofthecervicofacialdivisionofthefacial
nerve.Inallindividuals,thisbranchcrossessuperficialtothefacialveinwithin2cm
beneaththeangularnotchofthemandible,whereinthefacialvesselscanbepalpated.
Fromthispositionitascendstowardtheangleofthelipssothatanteriortothepositionof

thefacialarteryitcrossesthelowerborderofthemandibletosupplythemusclesofthe
cornerofthemouthandlowerlip.
Thecurvedcourseofthisnerveandthesimilarlyshapedcoursesofothernervesinthis
regionhaveledtothetermneuralhammocks.Themandibularnerveformsthefirstof
suchhammocksofthesubmandibulartriangle.Skandalakisetal.sawthis
hammockhangingsofarbelowthemandiblethatahightransverseincisionwouldhave
severedit.16
Themandibularbranchofthefacialnervealwayspassesposteriortotheangleofthe
mandible.Itliesbetweentheplatysma
andthedeepcervicalfascia(generalinvestinglayer),andproceedstosupplythe
quadratuslabiiinferiorismuscle.
Thecervicalbranchofthefacialnervedividestoformdescendingandanteriorbranches.
Thedescendingbranchinnervatestheplatysmaandcommunicateswiththetransverse
cervical(C2,C3)andgreatauricular(C2,C3)cutaneousnervesoftheneck.Theanterior
branch,theramuscolimandibularis,crossesthemandiblesuperficialtothefacialartery
andvein,andjoinsthemandibularbranchtocontributetotheinnervationofthemuscles
ofthelowerlip.Thisanteriorbranchformsthesecondneuralhammockofthetriangle.It
isfrequentlyconfusedwiththemandibularhammock.
Injurytothemandibularbranchofthefacialnerveresultsinaveryslightdroopingofthe
cornerofthemouth.Thedroopingisnotnoticeablewhenthemouthisinreposeonly
whenitisinmotion(smiling).Dependingonthenatureoftheinjury,thedroopingmay
beneuropraxiaorpermanent.Rememberthattheorbicularisorisandthemuscles
innervatedbybuccalbranchesactuallyraisethecommissureontheaffectedside.Injury
totheanteriorcervicalbranchproducesminimaldroolingthatwilldisappearin4to6
months.
Skandalakisetal.16measuredthedistancebetweenthesetwoneuralhammocksandthe
lowerborderofthemandiblein40cadavers(80cervicofacialdissections).These
measurementsareshowninFig.116.In50percentofthespecimens,themandibular
branchwasabovethemandibularborderandthusoutsidetheboundariesofthe
submandibulartriangle.Inasimilar
study,DingmanandGrabb17foundthebranchtobeabovetheborderin81percentof
theirspecimens.Iftheskinincisionisplacedatleast4cmbelowtheborderofthe
mandible,evenanexceptionallylowcervicalbranchwillnotbeaccidentallycut.
FIG.116.
Page24of203
Theneuralhammocksformedbythemandibularbranch(upper)andtheanterior
ramusofthecervicalbranch(lower)ofthefacialnerve.Thedistancebelowthemandible
isgivenincentimeters.Percentagesindicatethefrequencyoftheconfigurationin80
dissectionsofthesenerves.(FromSkandalakisJE,GraySW,RoweJSJr.Surgical
anatomyofthesubmandibulartriangle.AmSurg1979;45:590596;withpermission.)
AstudyofChineseadultsdemonstratedthatin67%themarginalmandibularbranchran
abovethelowerborderofthemandible,suggestingtheexistenceofethnicvariationsin
thetopographyofthenervebranches.18

SecondSurgicalPlane:TheContentsoftheSubmandibularTriangle
Thestructuresofthesecondsurgicalplane,fromsuperficialtodeep,arethefacial
(anteriorfacial)vein,theretromandibular(posteriorfacial)vein,partofthefacial
(externalmaxillary)artery,thesubmentalbranchofthefacialartery,thesuperficiallayer
ofsubmaxillaryfascia(deepcervicalfascia),thelymphnodes,thedeeplayerof
submaxillaryfascia(deepcervicalfascia),andthehypoglossalnerve(XII)(Fig.117).
FIG.117.
Page25of203
Thesecondsurgicalplaneofthesubmandibulartriangle.Thesuperficialportionof
theglandisexposed.(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.Surgical
anatomyofthesubmandibulartriangle.AmSurg1979;45:590596;withpermission.)
Theretromandibularvein,formedbytheunionofthesuperficialtemporalandmaxillary
veins,dividesneartheangleofthemandibleintoanteriorandposteriordivisions.The
posteriordivisionjoinstheposteriorauricularveintoformtheexternaljugularvein.The
anteriordivisionpassesforwardtojointhefacialvein,whichisinferiortothemandibular
notch,therebyformingthe
commonfacialvein.13
Itisnecessarytorememberthatthefacialarterypiercesthestylomandibularligament.
Thisligament,whichmostoftenisthickbutsometimesisthin,extendsfromthestyloid
processtotheangleofthemandible,withoccasionalextensionstothestylohyoidmuscle
andtheposteriorbellyofthedigastricmuscle.Theligamentisaparticularlythickened
portionofthedeeplayerofthefascialcapsuleoftheparotid,whichisderivedfromthe
superficialinvestinglaminaofthedeepfasciaoftheneck;it
separatestheparotidandsubmandibularglands.Jovanovic19describedthisligament,
emphasizingitsimportanceinclinicalandsurgicalanatomy.Itmustbeligatedbeforeit
iscuttopreventbleedingafterretraction.Also,itisimportanttorememberthatthe
lymphnodesliewithintheenvelopeofthesubmandibularfascia,incloserelationship
withthegland,andthatnodes
Page26of203
occuralongfacialvessels(thisisimportantintreatingmetastaticskincancers).
Differentiationbetweenglandsandlymphnodesmaybedifficult.
Thefacialveinandtheanteriordivisionoftheretromandibularveincrossthetrianglein
frontofthesubmandibulargland,anduniteclosetotheangleofthemandibletoformthe
commonfacialvein.Thecommonfacialveinemptiesintotheinternaljugularveinnear
thegreatercornuofthehyoidbone.Itiswisetoidentify,isolate,clamp,andligateboth
thefacialveinandtheanteriordivisionoftheretromandibularvein.
Thefacialartery,abranchoftheexternalcarotidartery,entersthesubmandibular
triangleundertheposteriorbellyofthedigastricmuscleandunderthestylohyoidmuscle.
Atitsentranceintothetriangle,itisunderthesubmandibulargland.Aftercrossingthe
glandposteriorly,thearterypassesoverthemandible,alwayslyingundertheplatysma.It
canbeligatedeasily.
ThirdSurgicalPlane:TheFlooroftheSubmandibularTriangle

Thestructuresofthethirdsurgicalplane,fromsuperficialtodeep,includethemylohyoid
musclewithitsnerve,thehyoglossusmuscle,themiddleconstrictormusclecoveringthe
lowerpartofthesuperiorconstrictormuscle,andpartofthestyloglossusmuscle(Fig.1
18).
FIG.118.
Thethirdsurgicalplaneofthesubmandibulartriangle.Thesuperficialportionofthe
glandhasbeenremovedandthedeepportionisvisibleundertheedgeofthemylohyoid
muscle.(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.Surgicalanatomyofthe
submandibulartriangle.AmSurg1979;45:590596;withpermission.)
Page27of203
MylohyoidMuscle.AccordingtoDuPlessis,20themylohyoidmusclesareconsidered
toformatruediaphragmforthefloorofthemouth,withthegeniohyoidmuscleandthe
musclesofthetongueabove,andtheanteriorbelliesofthedigastricmusclesandamajor
portionofthesubmandibularglandbelow.Themylohyoidarisesfromthemylohyoidline
oftheinnersurfaceofthemandible;itsmoreposteriorpartinsertsonthebodyofthe
hyoidbone,anditsmoreanteriorpartinsertswiththeoppositemylohyoidintothe
midlineraphebetweenthehyoidboneandthemandible.Thesuperiorsurfaceofthe
mylohyoidisinrelationshipwiththelingualandhypoglossalnerves.
SehirliandCavdar21reportedacaseofaleftaccessorymylohyoidmuscle,located
betweentheanteriorbellyofthedigastricandthenormalmylohyoidmuscles.Theleft
accessorymylohyoidmuscleextendedfromthemylohyoidlineofthemandibletothe
lowerpartofthemylohyoidrapheandhyoidbone.
HyoglossusMuscle.Thethinandquadrilateralhyoglossusmusclearisesfromthegreater
hornandbodyofthehyoidbone.Itascendsalmostverticallyintothesideofthetongue
betweenthestyloglossusmusclelaterallyandtheinferiorlongitudinalmusculatureofthe
tongue.Thehypoglossalnerveanditsvenaecomitantesenterthefloorofthemouthover
theposterioredgeofthemylohyoid,lateraltothehyoglossus.Fromitsoriginintheneck,
thelingualarterypassesdeeptothehyoglossusmuscle.Itentersthefloorofthemouth
betweenthehyoglossusmusclelaterallyandthegenioglossusmusclemedially.
Thenervetothemylohyoid,whichalsosuppliestheanteriorbellyofthedigastric,arises
fromtheinferioralveolarbranchofthemandibulardivisionofthetrigeminalnerve.The
mylohyoidnerveliesontheinferiorsurfaceofthemuscle,betweenitandthedigastric.
Thesubmandibularspacecanbethoughtofasthecombinationofthesublingualand
submaxillaryspaces.
MiddleConstrictorMuscle.Themiddleconstrictororiginatesfromtheanglebetweenthe
lesserandgreaterhornsofthehyoidboneandfromthestylohyoidligament.Itsinsertion
isthemedianraphe.Thefiberstravelbackward,withthehighestascendingand
overlappingthesuperiorconstrictor,andthelowestfiberstravelingdownunderthe
inferiorconstrictor.
StyloglossusMuscle.Thestyloglossusmusclehastwooriginsandtwoinsertions.The
originsarefromthefrontareaofthestyloidprocessandfromthestylomandibular
ligament.Insertionsareintothesideofthetongueandatitsinferiorarea.

SubmandibularSpaceandLudwigsAngina.Thesublingualandsubmaxillaryspaces,
aboveandbelowthemylohyoidmuscle,respectively,arecontinuousattheposterior
borderofthemylohyoid.Thesespacescanbeinvolvedinthediffuseinflammation
(cellulitis)ofLudwigsangina,whichoftenresultsfrominfectionsofthelowermolar
teeth,mostcommonlywithstreptococcus
hemolyticusastheinfectiousagent.AsnotedbyLindner,22theentiresubmandibular
spaceisboundedtightlybytheattachmentsofthecervicalinvestingfasciatothe
mandible,themucousmembraneofthefloorofthemouth,theattachmentofcervical
fasciatothehyoidbone,thehyoidboneitself,andthefascialinvestmentoftheposterior
bellyofthedigastric.Edemahere,andtheswollenanddisplacedtonguecancause
asphyxiation.Infectionofthesubmandibularspacecanspreadposteriorlyalongthe
styloglossusmuscleintothepharyngomaxillaryspace.Fromthisregion,theprocesscan
passintotheretropharyngealspaceandtheninferiorlyintothesuperiormediastinum.
Remember,inLudwigsangina(asurgedbyLindner22):
Celluliticareasshouldnotbeincised.Incisionsinviteadditionalforeignorganismsinto
anareathatfrequently(andearly)
becomesgangrenous.
Cellulitisshouldbemetwithsystemictreatmentwithspecificantibiotictherapy,and
withlocaltreatmentwithmassivehotcompressesandhourlyhotsalinegavagestothe
oralcavity.Intravenoustherapyshouldbeusedtomaintainfluidandelectrolytebalances.
Toavoidasphyxiation,maintenanceofanadequateairwayisofutmostimportance.
Tracheotomyisimperativeifthebreathingbecomesshallowandrapid.
Surgicaldivisionofthefasciaandmylohyoidisperformedonlyforcomplicationssuch
asdrainageofpusundertension,erosionofcervicalvesselsbytheinfectiousprocess,
andinternaljugularveinthrombosis.
Page28of203
FourthSurgicalPlane:TheBasementoftheSubmandibularTriangle
Thestructuresofthefourthsurgicalplane,orbasementofthetriangle,includethedeep
portionofthesubmandibulargland,thesubmandibular(Whartons)duct,thelingual
nerve,thesublingualvein,thesublingualgland,thehypoglossalnerve(XII),andthe
submandibularganglion(Fig.119).Theuncinatepartofthesubmandibularglandrounds
theposteriorborderofthemylohyoidtolieintheconnectivetissueaboveit.Here,the
submandibularductarisesandpassesthroughthefloorofthemouthtoendatthe
sublingualcarunclebesidethefrenulumofthetongueanteriorly.
FIG.119.
Thefourthsurgicalplaneofthesubmandibulartriangle.Thedeepportionofthegland
andductareexposed.(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.Surgical
anatomyofthesubmandibulartriangle.AmSurg1979;45:590596;withpermission.)
Thesubmandibularductliesbelowthelingualnerve(exceptwherethenervepasses
underit)andabovethehypoglossalnerve.LymphaticDrainage
Thesubmandibularlymphnodesreceiveafferentchannelsfromthesubmentalnodes,the
oralcavity,andtheanteriorpartsoftheface.Efferentchannelsdrainprimarilyintothe
jugulodigastric,jugulocarotid,andjuguloomohyoidnodesofthechainaccompanyingthe

internaljugularvein(deepcervicalchain).Afewchannelspassbywayofthesubparotid
nodestothespinalaccessorychain.
Thecontentsofthesubmandibulartriangleareclearedoutduringradicalneckdissection
byremovingthesubmandibular(submaxillary)glandanditsenvelopeandlymphnodes
within,andbyremovingitscapsuleandallsurroundingtissuewithout.
SUBMENTALTRIANGLE
Boundaries
Theboundariesofthistriangleare:
Page29of203
Lateral:anteriorbellyofthedigastricmuscleInferior:hyoidbone
Medial:midline
Floor:mylohyoidmuscle
Roof:skinandsuperficialfasciaContents
Thesubmentaltrianglecontainslymphnodes.Thecontentsofthistriangleshouldbe
sacrificedinradicalneckdissection.23LymphaticDrainage
Thelymphnodesofthesubmentaltrianglereceivelymphfromtheskinofthechin,the
lowerlip,thefloorofthemouth,andthetipofthetongue.Theysendlymphtothe
submandibularandjugularchainsofnodes.
CAROTIDTRIANGLE
Boundaries
Theboundariesare:
Posterior:sternocleidomastoidmuscle
Anterior:anterior(superior)bellyoftheomohyoidmuscle
Superior:posteriorbellyofthedigastricmuscle
Floor:hyoglossusmuscle,inferiorconstrictorofthepharynx,thyrohyoidmuscle,
middleconstrictorofthepharynx,longuscapitusmuscle
Roof:investinglayerofdeepcervicalfasciaContents
Thecarotidtrianglecontains:
bifurcationofthecarotidartery
internalcarotidartery(nobranchesintheneck)branchesoftheexternalcarotidartery
superiorthyroidartery(rare)posteriorauricularartery
superficialtemporalarteryinternalmaxillaryartery
occipitalartery
ascendingpharyngealarterysternocleidomastoidarterylingualartery(occasional)
Page30of203
externalmaxillaryartery(occasional)
facialartery(occasional)
tributariesoftheinternaljugularvein
superiorthyroidvein
pharyngealveinvagusnerve
spinalaccessorynerve
hypoglossalnerve

ansahypoglossi
cervicalsympathetictrunks(partial)
Protectionofnervesandvessels,andremovalofthelymphatictissueisessential.
Theposteriorbellyofthedigastricmusclewhichisbetweenthesubmandibularand
carotidtrianglesisareliablelandmarkinadangerousarea.Deeptotheposteriorbelly,
thefollowinganatomicentitieswillbefound:
internalandexternalcarotidarteries
internaljugularvein
glossopharyngealnerve(9thcranialnerve)spinalaccessorynerve(11thcranialnerve)
hypoglossalnerve(12thcranialnerve)
sympathetictrunk
LymphaticDrainage
Lymphisreceivedbyjugulodigastric,jugulocarotid,andjuguloomohyoidnodes,andby
nodesalongtheinternaljugularveinfromthesubmandibularandsubmentalnodes,the
deepparotidnodes,andtheposteriordeepcervicalnodes.Lymphpassestothe
supraclavicularnodes.
MUSCULARTRIANGLE
Boundaries
Theboundariesare:
Superiorlateral:anteriorbellyoftheomohyoidmuscle
Inferiorlateral:sternocleidomastoidmuscle
Medial:midlineoftheneck
Floor:prevertebralfasciaandprevertebralmuscles;sternohyoidandsternothyroid
musclesRoof:investinglayerofthedeepfascia;strap,sternohyoid,andcricothyroid
muscles
Contents
Themusculartrianglecontainsthethyroidandparathyroidglands,trachea,esophagus,
andsympatheticnervetrunk.According
Page31of203
toBeahrs,23thistriangleistheleastimportant.
Rememberthatoccasionallythestrapmusclesmustbecuttofacilitatethyroidsurgery.
Theyshouldbecutacrosstheupper
thirdoftheirlengthtoavoidsacrificingtheirnervesupply.
EditorialCommentIthasbeenmypracticetoroutinelydividethestrapmusclesin
thyroidsurgery,dividingbetweentheupperonethirdandlowertwothirds.This
providesexcellentexposure,andIbelieveitaddstothesafetyoftheprocedure.When
thestrapmusclesaredivided,itisnotnecessarytoraisesubplatysmalflaps.Thisisawell
toleratedincisionforthepatientandprovidesexcellentexposureandvisualizationforthe
surgeonandtheassistant.(RogerS.Foster,Jr.,MD)
LymphaticDrainage
Lymphaticdrainageofthemusculartrianglewillbediscussedwiththethyroidgland.
PosteriorCervicalTriangle

Theposteriorcervicaltriangleissometimesconsideredtobetwotrianglestheoccipital
andthesubclavianwhicharedividedbytheposterior(inferior)bellyoftheomohyoid
muscle(Fig.120).Wewilltreatitasoneentity.
FIG.120.
Theposteriortriangleoftheneck.Thetrianglemaybedividedintotwosmallertriangles
bytheomohyoidmuscle.(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.
AnatomicalComplicationsinGeneralSurgery.NewYork:McGrawHill,1983;with
permission.)
BOUNDARIES
Page32of203
Theboundariesare:
Anterior:sternocleidomastoidmuscle
Posterior:anteriorborderofthetrapeziusmuscle(Fig.121)
Inferior:clavicle
Roof:superficialinvestinglayerofthedeepcervicalfascia
Floor:prevertebralfasciaandmuscles,spleniuscapitusmuscle,levatorscapulae
muscle,andthreescalenemuscles
FIG.121.
Theflooroftheposteriortriangle.
CONTENTS
Betweentheinvestingfasciaandtheprevertebralfasciaaretheaccessorynerve(XI)and
aportionoftheexternaljugularvein.Variablydeepwithinthetrianglearethesubclavian
artery,subclavianvein,cervicalnerves,brachialplexus,phrenicnerve,accessoryphrenic
nerve,spinalaccessorynerve,andlymphnodes.
LYMPHATICDRAINAGE
Superficialoccipitallymphnodesreceivelymphfromtheoccipitalregionofthescalp
andthebackoftheneck.Efferentvesselspasstoadeepoccipitallymphnode(or
occasionallytomorethanonenode)whichdrainsintodeepcervicalnodesalongthe
spinalaccessorynerve.
Page33of203
SURGICALNOTES
Thefollowingaresurgicalpointstorememberfortheupperoroccipitalpartofthe
posteriortriangle:
Clearthelymphnodesaroundthespinalaccessorynerveverycarefully.
Sacrificethenerveifitisabsolutelynecessary.
Surgicalpointsforthelowerorsubclavianpartoftheposteriortriangle:
Becarefulwiththetrianglescontents:thesubclavianvein,portionsofthetransverse
cervicalvessels,andlymphnodes.
SurgicalApplicationsoftheCervicalTriangles
ANTERIORTRIANGLE
Inthepast,inflammatoryprocessesintheneck,suchasLudwigsangina,presented
withseveremortalityandmorbidity.Althoughtheseinflammatoryprocessesstilloccur,

theyarefarlesscommon,withlowermortality,becauseeffectiveantibioticsarrestand
curetheinflammation.
Donotconfusethecarotidsinusandthecarotidbody.Anatomically,thecarotidsinusis
adilatedareathatisusuallylocatedatthebeginningoftheinternalcarotidartery.There,
themediaisthinandpoorinmuscle.Buttheadventitiaisthick;itisrichwithelastic
tissue,receptors,andsensorynervefibersfromtheglossopharyngealnerve.
Thecarotidsinus(Fig.122)actsasabaroreceptor,respondingreflexivelytochangesin
arterialpressure.Elevationofpressureorcompressionofthecarotidsinuscanresultin
slowingoftheheartrate,asuddenfallinarterialpressure,cerebralischemia,and
ipsilateralandsecondarysyncope.
FIG.122.
Page34of203
Diagramofthecarotidsinus,carotidbody,andtheirinnervation.Whatpartthe
carotidbranchofthevagusplaysinthisinnervationisnotknown.Notethatthecarotid
bodyliesnotsomuchin,asmedialto,thecarotidbifurcation.
Thecarotidbody(Fig.122)isatinybilaterallobularanatomicentity2to7mminsize.
Itislocatedatthecarotidbifurcationor
ontheposteriormedialsideofthecommoncarotidartery.24Itmaybepartially
embeddedinthecarotidadventitiafromwhichitdevelopedembryologically.Itis
composedofafibrouscapsulewithseptaewhichdivideitintolobulescomposedof
epithelioidglomuscells,supportingcells,andsinusoids.Tumorsofthecarotidbodymay
developandpresentserioussurgicalproblems,particularlywithregardtohemorrhage
duringsurgery.
Thecarotidbodyisachemoreceptorwhichissensitivetolowlevelsofoxygen,high
levelsofcarbondioxide,orhydrogenionconcentrations.Itrespondstotheseby
reflexivelyincreasingrespiratoryventilationviaitsconnectionswiththebrainstem.Its
nervesupplyisderivedprincipallyfromtheglossopharyngealnerve,althoughitalso
seemstoreceivefibersfromthevagus.
POSTERIORTRIANGLE
Page35of203
Thesubclavianarterycanbecompressedagainstthefirstribbypressureofthe
thumbplacedinthesupraclavicularfossawhenthehandisgraspingtheneck.
Oneofthemostcommonfracturesisthatoftheclavicle,perhapsdueinparttothefact
thatthemiddleonethirdoftheclavicleisnotprotectedbymuscularattachments.The
subclaviusmuscledoesnothavethepowertoprotecttheclavicle.
Theaccessorynerve(XI)dividestheposteriortriangleintotwonearlyequalparts.
BorrowingfromtheterminologyofGrant
andBasmajian,25werefertotheupperareaascarefree,andthelowerareaas
careful.Thepositionoftheaccessorynerveintheposteriortrianglecanbeascertained
asfollows.First,placeapointontheanteriorborderofthetrapeziusonethirdofthe
distancebetweentheacromionprocessandthebackoftheskull.Second,placeapointon
theposteriorborderofthesternocleidomastoid,twothirdsofthedistancefromthe

clavicletothemastoidprocess.Alinedrawnbetweenthetwopointswilllieoverthe
courseoftheaccessorynerve,deeptotheinvestingfascia.Erbspoint,wherethe
externaljugularcrossestheposteriorborderoftheSCM,emphasizestheexitofthe
greaterauricularnervealongwithcranialnerveXI.
WequotefromKierneretal.26ontheanatomyofthespinalaccessorynerve(SAN)and
thetrapeziusbranchesofthecervicalplexus:
(1)TheSANcanbefoundmedialaswellaslateraltotheinternaljugularvein,
dependinghowfarcranialintheneckitisidentified.Thecrossingbetweenthese2
importantstructurescanhappenonlydorsally(44%)orventrally(56%)totheinternal
jugularvein...
(2)WhentheSANpassesthroughthesternocleidomastoidmuscle,ittakesanSshaped,
3dimensionalcourseinsteadofrunningstraightthroughthemuscle...Ifthenervewere
followedthroughthemuscle...thecommunicatingbranch(es)withthecervicalplexus
wouldobviouslybecut.
(3)Thecervicalplexusbranchespassingtothetrapeziusmusclearealwayssubfascial
becauseanotherrelationshiptothefasciaeoftheneckwhethersuperficialordeepis
anatomicallyimpossible.
(4)TheSANcaneasilybemixedupwiththeminoroccipitalnervebecausethelatter
sometimestakesasimilarcourse,turningupwardjustslightlymedialtotheanterior
borderofthetrapeziusmuscle...Therefore,thesupposedSANmustbefollowedrightto
theanteriorborderofthetrapeziusmuscletobesurethatitkeepsitscraniocaudal
direction.Furthermore,wefoundthatmeasuringattheposteriorborderofthe
sternocleidomastoidmusclefromtheclavicleprovidesthemostreliableresultsandthat
thenervecanalwaysbeidentified.Theotherlandmarkscitedintheliterature,suchasthe
greatauricularnerveorthesternocleidomastoidmuscleitself,showmuchmore
variability.
Inafewpreparations,cutaneousbranchesoftheposteriorspinalnervespassedthrough
thetendonplanebetweenthespinousprocessesofthevertebralcolumnandthetrapezius
muscletoreachtheskin.However,incontradictiontosomeformerworks,theywere
neverfoundtobranchwithinthemuscle,whichwouldhaveindicatedadditional
innervation.
Thefollowingaredescriptionsoftheanatomicentities(fromabovedownward)within
thecarefulareas,aswellassomeindicationsabouttheirpotentialforinjury.
Thespinalaccessorynerveiscloselyrelatedtothedeepposteriorcervicalnodes.Ifan
abscessispresentinthisarea,makeanincisionjustthroughtheskin.Useahemostatto
penetrateanddraintheabscess.Thismethodavoidsinjurytothenervewithresultant
wastingofthetrapeziusanddroopingoftheshoulder.
Thebrachialplexuscanbeinjuredinthelowerpartofthetrianglebysuchdiverse
meansasstabwounds,bullets,excessiveabnormaltractionatchildbirth,fallsuponthe
shoulder,orothersourcesofblunttrauma.
Thesubclavianarteryandthebrachialplexuscanbecompressedastheycrossthefirst
ribposteriortotheanteriorscalenemuscle.
Page36of203

Thephrenicnervepassesinferiorlyontheventralsurfaceoftheanteriorscalene
musclebeneaththecoveringoftheprevertebralfascia.Becausethisfasciaisdrawn
distallyastheaxillarysheathuponthebrachialplexusandaxillaryartery,anesthetics
injectedintothesheathcanaffectthephrenicnerve,resultinginahemiparalysisofthe
diaphragm.
Thetopographicpathwayandrelationsofthephrenicnervewithotheranatomicentities
intheneck:1.Posteriortotheinferiorbellyoftheomohyoidmuscle,veryclosetoits
intermediatetendon
2.Posteriortotheinternaljugularvein,transversecervical,andsuprascapulararteries
3.Posteriortothethoracicductontheleftneck
4.Anteriortothesubclavianartery5.Posteriortothesubclavianvein
WequotefromKlineetal.27:
Thesurgeoncanfeelthecharacteristicroundedanteriorborderofthescalenusanticusas
heorshepalpatesthroughthefatandlymphoidtissue.Thisisanimportantclue,asthe
novicetendstooperatetoofarlaterallyandsuperiorly,therebymissingthebrachial
plexusaltogether.Thesurgeoncancleardowntotheanteriorborderofthescalenus
anticuswithdispatch,knowingthatthephrenicnerveisdeeptotheprevertebralfasciaat
thispoint.Oncethephrenicnervehasbeendissectedfreeandguarded,thescalenus
anticuscanbedividedafterthesurgeonhasseenthatthesubclavianarteryisfreefromits
posteriorsurface.
NOTE:Atthatpoint,thephrenicnerveentersthethoraciccavity,anteriortotheinternal
thoracicarteryandtothepulmonaryhilum,betweenthemediastinalpleuraandthe
pericardium.Herethepericardiophrenicvesselsarefellowtravelersofthephrenicnerve.
Thecervicalpleuraandtheapicalpartsofthelungsextendupwardabovetheclavicle
intotherootoftheneck.Scalenelymphnodebiopsycanproduceiatrogenic
pneumothoraxorinjurytotheapexofthelung,aswellasinjurytothehighestpartofthe
leftthoracicduct.
Theexternaljugularveinpassesdownwardfromtheareaoftheangleofthemandible
tothemiddleoftheclavicle.Justabovetheclavicle,theveinpiercestheinvestingfascia
anddrainsintothesubclavianvein.Inthisarea,apenetratingneckwoundwithdivision
oftheveincanallowairtobesuckedintotheveinbecausethedeepfasciaisfixedfirmly
tothevenouswall,therebykeepingthelumenoftheveinopen.Duringinspirationafatal
airembolismmaytakeplace.
Remember,therearethreetopographicfeaturesinthevicinityofthesupraclavicular
triangleregionofthecarefulpartoftheposteriortriangle.Theinterscalenegrooveand
thesupraclavicularfossaarepresentwithinthetriangle;theinfraclavicularfossais
locatedjustunderthemiddleonethirdoftheclavicle,outsideoftheposteriortriangle
(Figs.123,124).
FIG.123.
Page37of203
Page38of203
Thesupraclavicularfossa,theinfraclavicularfossa,andthejugularfossa.

FIG.124.
Page39of203
Compressionofthesubclavianarteryandbrachialplexus.A,muscleisrelaxed;B,
contractionoftheanteriorscalenemuscleinthepresenceofacervicalribcanproduce
compressionofthesubclavianarteryandbrachialplexus;C,scalenotomyalonemay
relievethiscompressionbyallowingthevesselandnervestodropforward.
InterscaleneGroove:Iftheheadisturnedstronglytotheoppositeside,atriangleis
formedbytheclavicleinferiorly,thesternocleidomastoidmusclemedially,andthe
anteriorborderofthetrapeziusmusclelaterally.Theanteriorandmiddlescalenesliein
thefloorofthistriangle.Indifferentindividuals,thegroovebetweenthemcanbe
palpatedwithvaryingease.
Thepositionofthecricoidcartilagecanbeusedtoapproximatethelevelofthe6th
cervicalvertebra.Likewise,ChassaignacstubercleofthetransverseprocessofC6canbe
palpatedjustbehindtheposteriorborderofthesternocleidomastoid.Apointlocatedin
suchfashioninthemiddleofthetriangleapproximatesthesiteofthepassageofthe
subclavianarteryandtheemergingofthebrachialplexusfrombetweentheanteriorand
middlescalenes.Thesecondpartofthesubclavianarteryliesbehindtheanteriorscalene
muscle.Afingerpasseddownwardpalpatinginthe
interscalenegroovewillusuallyfeelthepulseofthesubclavianarterywithout
difficulty.28
TheSupraclavicularFossa:Thesupraclavicularfossaisformedbythelateral
(posterior)borderofthesternocleidomastoidmuscle,theanteriorborderofthetrapezius,
andtheproximalonehalforonethirdoftheclavicle.Thisisthepressurepointofthe
subclavianartery,whichmaybepalpatedbetweenthefingerandthefirstrib.
TheInfraclavicularFossa:Theinfraclavicularfossaisthesoft,palpablehollowlocated
inferiortothemiddleoftheclavicle.Itisboundedbythepectoralismajor,deltoid,and
clavicle.Theaxillaryveinappearsdeeptotheskin,superficialfascia,andclavipectoral
fascia.Theaxillaryartery,boundedbyelementsofthebrachialplexus,islocateddeepto
theaxillaryvein.Theapicalandinfraclavicularlymphnodesalsoarefoundinthisfossa.
Theanteriorscalenemusclearisesfromtheventraltuberclesofthetransverseprocesses
ofthe4ththroughthe6thcervicalvertebrae.Itdescendsalmostverticallytoinsertonthe
scalenetubercleofthefirstrib,anteriortothegrooveforthesubclavianartery.The
middlescalenemuscle,thelargestofthethreescalenes,arisesfromtheposterior
tuberclesofthetransverseprocessesofvertebraeC2C7.Itinsertsonthefirstrib
betweenitstubercleandthesubclavianarterygroove.Theposteriorscalenearisesfrom
theposteriortuberclesofvertebraeC4C6.Itinsertsuponthesecondrib.
Harryetal.29reportedthatthecommonlydescribedanatomicrelationshipofthebrachial
plexuslocatedbetweentheanteriorscaleneandmiddlescalenemuscleswasfoundonly
in60percentofcases.Thesameauthorsobservedthefollowingvariations:
Thescalenusminimusmusclewaspresentin46percentofinstances(Fig.125)
In15percentofcasestheanteriorscalenemusclewaspenetratedbyfusedC5C6roots
FIG.125.
Page40of203

Variationsseeninrelationsbetweenscalenemusclesandthebrachialplexus.A,
subclavianarterypiercingtheanteriorscalenemusclebelly;B,rootsofC5&C6piercing
theanteriorscalenemusclebelly.(ModifiedfromHarryWG,BennettJDC,GuhaSC.
Scalenemusclesandthebrachialplexus:anatomicalvariationsandtheirclinical
significance.ClinAnat1997;10:250252;withpermission.)
Thesubclavianveincrossesthefirstribventraltotheanteriorscalene,whereitisclosely
associatedwith,andoftencompressedby,thesubclaviusmuscle.Frequently,individuals
thusaffectedhavespontaneousoreffortrelatedupperextremityaxillaryandsubclavian
venousthrombosis(PagetvonSchroettersyndrome),unrelatedtointercurrentillnessor
iatrogenicmanipulation.Patientswiththisproblemcanbetreatedwithacombinationof
thrombolyticagentsandanticoagulation,
resectionofthefirstrib,andballoonangioplasty.30
Thoracicoutletsyndrome:Thesubclavianartery,incompanywiththebrachialplexus
andwithcontributionsfromcervicalnervesC5C8andthe1stthoracicnerve,passes
betweentheanteriorandmiddlescalenemuscles.Herethearteryandnervescrossthe
firstrib,andcanbesubjecttocompression.
Thoracicoutletsyndromeactuallyreferstocompressionattheupperopening(inlet,
superioraperture).Perhapstheuseoftheword"outlet"isincorrect,sincethelower
openingofthethoraxisthetrue"outlet."
Thetopographicrelationsofthethoracicinlet:Posterior:Firstthoracicvertebralbody
Page41of203
Anterior:SuperiorborderofthemanubriumofthesternumLateral:Firstrib
WequotefromObuchowskiandOrtiz31onmagneticresonance(MR)imagingofthe
thoracicinlet:
Thebordersofthethoracicinletdefineanobliqueplanethatanglesdownwardfromthe
spineanteriorlytothefirstribs.Itisthereforebesttoconsiderthethoracicinletasa
regionor"zone"whichextendsashortdistanceaboveandbelowthisplanetoincludethe
lowerportionoftheinfrahyoidneckandtheupperportionofthesuperiormediastinum.
MR'smultiplanarimagingcapacityallowsthethoracicinlettobesubdividedintofour
distinctzones:visceral,neurovascular,pulmonary,andspinal.
Poststenoticdilatationofthesubclavianarterycanbeassociatedwiththedevelopment
ofthrombi.Thesethrombi,dischargeddistallyintotheartery,canproduceconfusing
symptomssimilartocarpaltunnelentrapmentofthemediannerve.Sandersand
Pearce32observedthat86%ofpatientssufferingfromthoracicoutletsyndromehada
historyofsomeformofcervicaltrauma,especiallywhiplashinjuries.Insuchindividuals,
scalenectomyispreferabletoresectionofthefirstrib.
Accessoryscalenemusculature,fascialbands,oranatypical7thcervicalribcan,
variably,compresstheartery,thenerves,orboth.Thiscompressionresultsinscalenus
anticus(anteriorscalene)syndrome,withpain,paresthesiaorweakenedpulses.During
development,the7thcervicalribforms,andthennormallyregressestoitstransverse
process.Variationsinitsfatevaryfromafullyformedribtorudimentaryforms
associatedwithafibrocartilaginousband.

Inastudyof390transaxillaryresectionsofthefirstribforarterial,venous,orbrachial
plexuscompressionatthethoracicoutlet,
MakhoulandMachleder33foundthat66%ofthe175patientshadsingleormultiple
abnormalitiesrepresentingdevelopmentalvariations:86scaleneand39subclavius
muscleswereatypicalinformorattachments;20scalenemusclesweresupernumerary;
and17ribsexhibitedabnormalities(7thcervicaloratypical1stthoracic).
Inanotherstudyofpatientssufferingfromthoracicoutletsyndrome,Machlederetal.34
showedthatthereweredemonstrablemorphologictransformationsofanteriorscalene
musclefibersthatreflectmetabolicandenzymaticchangescharacteristicofvarious
adaptiveandpathologicprocesses.Insuchchanges,attributabletotraumaticstressand
stretchinjury,musclefiberschangefromafasttwitchtype2fibertoahypertrophied
slowtwitchtype1fiber.Suchchangesoccurpredominantlyinyoungindividualsin
responsetoexercise.
Thepresenceofacervicalrib(foundinabout1%ofcases)oftenwasshowntobe
indicativeofavariationinthescalenemusculatureorinthebrachialplexuswherethe
firstthoracicnervehadlittleinput,replacedbyamajorcontributionfromC4.Whenthe
C7ribwasincomplete,theregressedpartoftheribwasoftenreplacedbyafibrousband.
About67%ofcervicalribs
arebilateral.InMakhoulandMachleders33studyofpatientssufferingfromPagetvon
Schroettersyndrome,55%hadhypertrophyofthetendonofthesubclaviusmuscleas
wellasenlargementoftheinsertiontubercle.
PagetvonSchroettersyndromeisfrequentlyassociatedwiththrombosisoftheaxillary
subclavianveinfromexertion,leadingto
thephraseeffortveinthrombosis.Theconditiondevelopsasanabruptswellingofthe
upperextremity.AccordingtoFlye,35evenwithearlymedicaltreatmentcomplete
resolutionoccursinonly15%to30%ofpatients.
FasciaeoftheNeck
Thefollowingclassificationoftherathercomplicatedfascialplanesoftheneckfollows
theworkofseveralinvestigators:
SuperficialfasciaDeepfascia
Investinglayer(superficiallayer)
Middle,orpretracheal,layer(surroundingthelarynx,trachea,andpharynx)
Page42of203
Prevertebrallayer(posteriorordeeplayer)
SuperficialFascia
Thesuperficialfasciaoftheneckliesbeneaththeskin.Itiscomposedofloose
connectivetissue,fat,theplatysmamuscle,cutaneousbranchesofthecervicalplexus,the
cervicofacialdivisionofthefacialnerveandsmallcutaneousbloodvessels(Fig.126).
Thesurgeonshouldrememberthatthecutaneousnervesoftheneckandtheanteriorand
externaljugularveinsarebetweentheplatysmaandthedeepcervicalfascia.Iftheveins
aretobecut,theymustfirstbeligated.Becauseoftheirattachmenttotheplatysmaabove
andthefasciabelow,theydonotretract;bleedingfromthemcanbeserious,andthe

surgeonmustguardagainstthepossibilityofproductionofanairembolism.Forall
practicalpurposes,thereisnospacebetweenthislayerandthedeepfascia.
FIG.126.
Thesuperficialfasciaoftheneckliesbetweentheskinandtheinvestinglayerofthedeep
cervicalfascia.CT,connectivetissue.(ModifiedfromSkandalakisJE,GraySW,Rowe
JSJr.AnatomicalComplicationsinGeneralSurgery.NewYork:McGrawHill,1983;
withpermission.)
DeepFascia
INVESTINGLAYER
Thesuperficial(investing)layerofthedeepcervicalfascia(Figs.126and127)attaches
abovetotheoccipitalandtemporalbonesandthemandible,posteriorlytothespinesand
supraspinousligamentsofthecervicalvertebrae,andbelowtotheclavicle,scapula,and
manubriumofthesternum.Itenvelopstwomusclesthetrapeziusand
sternocleidomastoidandtwoglandstheparotidandsubmandibular.Itformstwo
spacesthesupraclavicularandsuprasternal;andformstheroofoftheanteriorand
posteriorcervicaltriangles.
FIG.127.
Page43of203
Fasciallayersandspacesabovethehyoidbone,inasagittalsection.Notethatthe
dangerspaceandtheretropharyngealspaceshownointerruption,butarecontinuous
withthedangerspaceandtheretrovisceralspace,respectively,belowthelevelofthe
hyoidbone.Notealsothatundernormalcircumstances,thesearepotential,ratherthan
actualspaces.(BasedonHollinsheadWH.AnatomyforSurgeons,Vol.1,2ndEd.
NewYork:Harper&Row,1968.)
PRETRACHEALLAYER
Themiddle(pretracheal)layerofthedeepfascia(Fig.128)issometimesdescribedas
investingthestrapmusclesanteriorly,mergingwiththesuperficialinvestinglayer.
Conversely,itisalsosaidtobealaminathatpassesdeeptothestrapmuscles,
unitingwiththesuperficialinvestinglayerlateraltothem.36Inkeepingwiththeformer
view,itissaidthataposteriorlayerofthepretrachealfasciaenvelopsthethyroidgland,
formingthefalsecapsuleofthegland(Fig.129).Thislayerisfixedtothethyroidand
cricoidcartilagesabove.Theattachmenttothecartilagesmaybethickenedtoformthe
suspensoryligamentofthethyroidgland(ligamentofBerry).
FIG.128.
Page44of203
Page45of203
Fasciallayersoftheneck.A,Crosssection.D,dangerspacewithinthe
prevertebralfascia;RV,retrovisceralorretropharyngealspacebetweentheprevertebral
fasciaandthepretracheal(visceral)fasciallayers.B,Chieffasciallayersoftheneck
belowthehyoidbone,inlongitudinalsection.(A,FromColbornGL,SkandalakisJE.
ClinicalGrossAnatomy:AGuideforDissection,Study,andReview.PearlRiverNY:

Parthenon,1993;B,modifiedfromHollinshead,AnatomyforSurgeons,Vol1:TheHead
andNeck,NewYork:Harper&Row,1968;withpermission.)
FIG.129.
Page46of203
Theanchorofthethyroidgland:theligamentofBerry.
Posteriorly,themiddlecervicalfasciabecomesilldefined,permittinganenlarging
thyroidglandtoextendposteriorly.Thisposterior,ordeep,portionofthepretracheal
fasciacanbethoughtofasthevisceralportionofthisfasciallayer.Itiscontinuous
posteriorlywiththebuccopharyngealandesophagealfasciae,asnotedsometimeagoby
GrodinskyandHolyoke.37Itisbecauseofthiscontinuitythatsomeprefertheterm
viscerallayertopretracheallayer,asthemoreappropriatenameforthemiddlelayer
ofdeepcervicalfascia.
Anteriorly,themiddlelayerattachesabovetothehyoidboneandbelowtothefibrous
pericardium.Laterally,itcontributestothecarotidsheath.Posteriorly,thisfasciallayer
continuesasbuccopharyngealfasciatothebaseoftheskull;itterminatesinferiorlyat
aboutthelevelofthebifurcationofthetracheabyblendingwiththealarpartofthe
prevertebralfascia.
PREVERTEBRALLAYER
Theprevertebral(posterior)layer(Fig.127)liesinfrontoftheprevertebralmuscles.It
originatesfromthespinousprocessesandtheligamentumnuchaeposteriorly,andcovers
thecervicalspinemuscles,includingthescalenemusclesandvertebralcolumn
anteriorly.Atitsattachmenttothetransverseprocessesofthecervicalvertebrae,the
prevertebralfasciadividestoformaspaceinfrontofthevertebralbodies,theanterior
layerbeingthealarfascia,theposteriorlayerretainingthedesignationofprevertebral
fascia.
CAROTIDSHEATH
Threefasciaeinvesting,pretracheal,andprevertebralcomposeafascialtube,the
carotidsheath(Fig.128,Fig.130),beneaththesternocleidomastoidmuscle.Withinthis
tubeliethecommoncarotidartery,internaljugularvein,vagusnerve,anddeepcervical
lymphnodes.Intheupperpartoftheneck,theconnectivetissueofthesheathblends
withthefascialinvestmentsofthestylohyoidmuscleandtheposteriorbellyofthe
digastric.Abovethis,thesheathbecomesmoreadherenttotheadventitialcoveringsof
thecarotidvesselsandinternaljugularvein.
Page47of203
FIG.130.
Twoviewsofthevisceralcompartmentoftheneck.
Page48of203
Inferiorly,thecarotidsheathisadherenttotheposterioraspectofthesternumand
clavicleandislateraltotheoriginsofthesternocleidomastoidandstrapmuscles.
Posteriorly,itisfusedwiththefirstribandSibsonsfascia.Intherootoftheneck,the
visceralfasciapassesontothealarfasciaofthecarotidsheath,continuingintothethorax

tothefibrouspericardiumoftheheartandgreatvessels.Asthesheathpassesintothe
thorax,theconnectivetissueofthesheathseparatelyencloseseachstructurewithinas
theydivergefromoneanother.
Behindthecarotidsheath,theprevertebralfasciacoversthescalenemusclesandphrenic
nerve,andprovidesoriginforthe
axillarysheath.ThepotentialdangerspaceofGrodinskyandHolyoke37(Figs.127and
128)liesbetweenthealarcomponentandthedeeper,muscularpartoftheprevertebral
fascia.Thisspaceprovidesaplaneforthespreadoffluidsorpathologicprocessesfrom
thebaseoftheskulltothethoracicdiaphragm.
BUCCOPHARYNGEALFASCIA
Thebuccopharyngealfascia(Fig.127)iscontinuousbelowwiththevisceralfascial
coveringoftheesophagus.Superiorly,itcoverstheposteriorandlateralsurfacesofthe
pharynxandcontinuesforwardovertheexternalsurfaceofthebuccinatormuscleofthe
cheek.Itisjoinedratherlooselybydelicateareolartissuetothealarlayerofthe
prevertebralfascia.Theintervalbetweenthetwofasciallayersistheretropharyngeal
space(Fig.127)whichextendssuperiorlytotheskullbaseandterminatesinferiorlyin
theupperpartofthethorax.Thisspacecanbeinfectedbydescendinginfections,by
directperforationsofthe
esophagus,orbyinfectionsofthedeepcervicallymphnodeswhichlieadjacenttoit.36
AXILLARYFASCIA
Theaxillaryfasciatakesitsoriginfromtheprevertebralfascia.Itisconsideredinthe
chapteronthebreastundertheheading
TopographicAnatomyandRelations:DeepFascia.
SpacesoftheNeck
Therearemanyspacesintheneckthataredefinedbythefasciae(Figs.127,128).
Becausethisbookisforthegeneralsurgeon,onlythosespacesthatneedspecial
emphasiswillbedescribed.Someothers,suchastheparotidandsubmaxillaryspaces,
willbediscussedwiththeorganstheyarerelatedto.Theauthoritativeworksonthe
cervicalspacesarethoseof
GrodinskyandHolyoke37andCollerandYglesias.38SpacesabovetheHyoidBone
Intrafascialspacesareformedbysplittingoftheseveralfasciallayersoftheneck.The
spacesarethoserelatedtothebodyofthemandible,andthesubmaxillary,parotid,and
masticatorspaces.
Peripharyngealspacesincludetheretropharyngeal,lateralpharyngeal,and
submandibularspaces.BuserandBart39studiedthenormalanatomyofthe
retropharyngealspace(Fig.127):thisinvolvestheposteriorneckintotofromthebase
oftheskulltothelevelofT1,T2intheuppermediastinuminfrontoftheprevertebral
fasciaandbehindthebuccopharyngealorvisceralfascia.Thelateralpharyngealspace
(Fig.131)isalateralextensionoftheretropharyngealspacearoundthepharynx.The
submandibularspace(Fig.127)isrelatedtotheanteriorelementsoftheseveral
peripharyngealspaces;itishighlycomplex.
FIG.131.
Page49of203

Partofadiagrammaticsemifrontalsection,slantedsomewhatanteriorlyfrombehind
theramusofthemandible,toshowtherelationsofthesuperficiallayeroffasciatothe
parotidgland.
SpacesbelowtheHyoidBone
Thefollowingarethespacesbelowthehyoidbone(Fig.128A&B,Fig.130):
Visceralcompartment(ofStiles)
Carotidsheath(seeCarotidSheathunderDeepFasciainthischapter)
Spacebetweentheprevertebralandalarfasciae,thedangerspaceofGrodinskyand
Holyoke37(seePrevertebralLayerunderDeepFasciainthischapter)
Thesuprasternalspace,orspaceofBurns.
VISCERALCOMPARTMENT
Theboundariesofthevisceralcompartmentoftheneck(thespaceofStiles)(Fig.130)
areasfollows:Anterior:Pretrachealfascia
Posterior:Prevertebralfascia
Lateral:Carotidsheath
Superior:HyoidboneandthyroidcartilagePosteroinferior:Posteriormediastinum
Page50of203
Anteroinferior:Bifurcationofthetrachea,atthelevelofthe5ththoracicvertebra
Thecontentsofthevisceralcompartmentarethelarynx,trachea,thyroid,parathyroid
glands,andpartoftheesophagus.
Thelowerpartofthevisceralcompartmentissubdividedintoananteriorpretracheal
spaceandaposteriorretrovisceral(retroesophageal)space.Thesespacesareseparatedby
lateralattachmentsoftheesophagustotheprevertebralfascia.The
spacesareconfluentabove.37
Thesespacesofthevisceralcompartment,togetherwiththecarotidsheath,arethechief
pathwaysofinfection.Pearse40statedthatinneckinfectionsthatspreadtothe
mediastinum,71percentspreadthroughtheretrovisceralspace,21percentthroughthe
carotidsheath,and8percentthroughthepretrachealspace.
SUPRASTERNALSPACE
Thesuprasternalspace(spaceofBurns)isformedbyasplittingofthesuperficial
investinglayerofthedeepcervicalfascia.Theanteriorlaminaisattachedtotheanterior
surfaceofthesternum.Theposteriorlaminaisattachedtotheposterioraspectofthe
manubrium.Withinthisspacearethelowerendsoftheanteriorjugularveinsandan
interconnectingvenousarch.Somelymphatictissueandfattytissueareoftenpresent
hereaswell.
SurgicalApplicationsoftheCervicalFasciaeandSpaces
Twoabscessesarerelatedtotheprevertebralfascia.Oneisanteriortoit,betweenthe
fasciaandtheposteriorlateralwallofthepharynx.Thisisanacuteretropharyngeal
abscess(Fig.132).Theotherislocatedbehindtheprevertebralfascia,issecondaryto
tuberculosisorotherosteomyelitisofacervicalvertebra,andischronic.
ThepretrachealcompartmentofStilesislimitedabovebythehyoidbone,andenters
belowintotheanteriormediastinum.Itcanbeapproachedsurgicallybyanykindof
incisionmedialtothesternocleidomastoidandcarotidsheath.

Collectionsoffluiddeeptotheprevertebralfasciacantrackdistallydowntheupper
extremitytotheleveloftheelbowbytransitwithintheaxillarysheath.
FIG.132.
Page51of203
Chronicandacuteretropharyngealabscesses.
VascularSupplyoftheNeck
Despitethefactthatwewillpresentthevascularsupplyofeachorganintheneck,atthe
presenttimetheoverallvascularsupplywillbepresentedinsummaryfashion.The
topographicanatomypresentedhereisbasedonMontgomery.41
Arteries
COMMONCAROTIDARTERIES
Theneckissuppliedbythecommoncarotidarteries.Therightcommoncarotidarises
fromthebifurcationofthebrachiocephalictrunkandtheleftcommoncarotidfromthe
aorticarch(Figs.133,134).
FIG.133.
Page52of203
Diagrammaticrepresentationofbothcommoncarotidarteries(posteriorview).
(ModifiedfromMontgomeryRL.HeadandNeckAnatomy:WithClinicalCorrelations.
NewYork:McGrawHill,1981;withpermission.)
FIG.134.
Page53of203
Commoncarotidarteryandinternalandexternalcarotidarteries.(Modifiedfrom
MontgomeryRL.HeadandNeckAnatomy:WithClinicalCorrelations.NewYork:
McGrawHill,1981;withpermission.)
GeneralTopography
Thecommoncarotidarterycanbedividedarbitrarilyintothreeparts:inferior,middleand
superior.Theinferiorpartisbehindthesternoclavicularjointontheright,andis
intrathoracicontheleft.Themiddlesectionislocatedintheneck.Thesuperiorpart
bifurcatestotheinternalandexternalcarotidarteries.
Inmostcasesthecommoncarotidarteryhasnobranchesintheneck.However,wehave
oftenseenthesuperiorthyroidarteryarisefromthesuperiorpartofthecommoncarotid
arteryjustbelowandclosetothebifurcation,whichisthemostcommonlocationofthe
carotidbody(Fig.135).
FIG.135.
Page54of203
Schemaoftheembryology,anatomy,andphysiologyofthecarotidbodyandcarotid
sinus,andthepathologyofthecarotidbody.(ModifiedfromSinghabhandhuB,Gray
SW,BryantMF,SkandalakisJE.Carotidbodytumors.AmSurg1973;39:501508;with
permission.)
Remember

Thecommoncarotidarteriesareenvelopedwithinthecarotidsheathtogetherwiththe
internaljugularveinandthevagusnerve.
Atitscranialend,theinternaljugularveinisventrolateraltothecommoncarotidartery.
Moreinferiorly,itbecomesdorsolateraltotheartery.
Thevagusnerveisbetweenthesetwovesselsinaposteromedialposition.
Page55of203
Thevertebralarterynormallyarisesfromthefirstpartofthesubclavianartery,
thereafterpassingintothetransverseforamenofthe6thcervicalvertebra.Inabout4%of
cases,theleftvertebralarteryarisesdirectlyfromtheaorticarch.Inapproximately6%of
cases,thevertebralarterymayenterthe7thor5thtransverseforamen;rarelyitentersat
evenhigherlevels.Thesurgicalsignificanceofhighentryisthatinsuchcasesthe
inferiorthyroidarterymaypassdeeptotheaberrantvertebralartery.Thisresultsina
potentialforfatalhemorrhageorinjurytootherstructuresifthearteryistornwhile
attemptingtomobilizetheinferiorthyroidartery.
Johnsonetal.42reportedthatearlyrecurrentstenosisofthecarotidarteryoccurredless
frequentlyafterendarterectomyusingpolytetrafluoroethylene(PTFE)patchangioplasty
thanwithprimaryclosureorindacronpatchangioplasty.
Relations
Topographically,theoriginoftherightcommoncarotidislocatedbehindtheright
sternoclavicularjoint.Theoriginoftheleftcommoncarotidisintrathoracic;asitenters
therootoftheneck,itpassesposteriortotheleftsternoclavicularjoint.Atthatlevelthe
twocommoncarotidarteriesare212312cmapart,separatedbythetrachea.Fromthat
point,bothcarotidarterieshavealengthof812cm,terminatingatthelevelofthe4th
cervicalvertebraandatthesuperiorlevelofthethyroidcartilage.Theretheybifurcateto
theexternalandinternalcarotidarteries.Thelarynxseparatesthemfromoneanotherat
512612cm.Thesurfaceanatomyofthecommoncarotidcanbeoutlinedbyaline
drawnfromthesternoclavicularjointtotheneckofthemandibleposteriorly.Ineach
triangle,thepathwayofthecommoncarotidsisdifferent.
Intheregionofthemusculartriangle,ahypertrophicthyroidglandwillcoverthe
commoncarotidartery;themiddlethyroidveincrossesanteriortotheartery.Toexplore
thearteryinthisarea,theplatysmamuscleandthesuperficialinvestinglayerofthedeep
cervicalfasciashouldbeincised,thesternocleidomastoidmuscleshouldberetracted
medially,andtheinfrahyoidmusclesandtheirfasciaeshouldalsobeincised.
Atthecarotidtrianglethearteryhasanterior,posteriorandmedialrelationsof
importance.Anteriorly,theplatysmamuscleandthesuperficialinvestinglayerofthe
deepcervicalfasciacovertheartery;there,abovetheomohyoidmuscle,thecarotidis
crossedbythesuperiorthyroidarteryandveinanditssternocleidomastoidbranch.
Theposteriorrelationsareasfollows:
Retropharyngealspace
Prevertebralfascia
Cervicalsympatheticnervesandganglia
Longuscolimuscle
Longuscapitismuscle

Anteriortuberclesofthetransverseprocessesofthe4th,5th,6th,and7thcervical
vertebraeVertebralarteryandvein
Medialtothecommoncarotidarethefollowinganatomicentities:Lowerpartofthe
pharynx
Thyroidcartilage
Cricoidcartilage
Lateralaspectofthethyroidlobe
Branchesoftheinferiorthyroidartery
Page56of203
RecurrentlaryngealnerveEsophagus
Trachea
Attherightsternoclavicularjoint,thecommoncarotidismedialtotheinternaljugular
vein.Theleftcarotidisbehindtheinternaljugularvein.Thethoracicductislocated
dorsaltothearteryontheleft.Therightrecurrentlaryngealnervecrossesthedorsalside
ofthefirstpartoftherightcommoncarotidartery.
VariationsofthegreatarteriesofthecarotidtrianglewerestudiedbyLucevetal.43inan
excellentpaperthatwerecommendtotheinterestedstudent.
CollateralCirculation
AccordingtoMontgomery,41collateralcirculationofthecommoncarotidartery(Fig.1
36)iscarriedonchieflyby:
Anastomosisoftheinternalcarotidofonesidewiththeinternalcarotidoftheopposite
sideandwithbothvertebralarteriesthroughthecerebralarterialcircle
Anastomosisoftheinferiorthyroidwiththesuperiorthyroid
Anastomosisofthedeepcervicalbranchofthecostocervicaltrunkwiththedescending
branchoftheoccipital
Anastomosisofthesuperiorthyroid,lingual,facial,occipital,andtemporalwith
correspondingarteriesoftheoppositesideAnastomosisoftheophthalmicwiththe
angular
FIG.136.
Page57of203
Someofthecollateralchannelsavailableafterligationofthecommoncarotidartery.
Ontherightsideofthebodyareshownthechiefcommunicationsbetweenthetwosides;
ontheleft,thechieflongitudinalanastomoses.
INTERNALCAROTIDARTERY
Theinternalcarotidartery(Fig.137)islocatedwithinthecarotidtriangle,underand
deeptothestylohyoidmuscleandtheposteriorbellyofthedigastricmuscle.Theinternal
carotiddoesnotgiveorigintoanybranchesintheneck,sinceitssupplyislimitedto
intracranialstructures.Itiscrossedlaterallybythehypoglossalnerve.
FIG.137.
Page58of203

Internalandexternalcarotidarteries.(ModifiedfromMontgomeryRL.HeadandNeck
Anatomy:WithClinicalCorrelations.NewYork:McGrawHill,1981;withpermission.)
AnaberrantinternalcarotidarterywasreportedbyColeandMay44asavascular
abnormalityofthemiddleear.Theseauthorswereabletocollect45cases.Paponetal.45
discussedtheexistenceofanastomosesbetweentheinternalcarotidand
vertebralarteries(orartery)intheneck.Thesefindingssuggestapossibleneedfor
modifyingsurgicaltechniqueduringendarterectomy.Mederetal.46reportedsixcasesof
segmentalagenesisoftheinternalcarotidartery.
Carstenetal.47recommendedDopplerscreeningexaminationstodetectasymptomatic
carotidstenoses.EXTERNALCAROTIDARTERY
GeneralTopography
TheexternalcarotidarterybeginsatthebifurcationofthecommoncarotidarteryatC4.It
continuesupwardtoapointposteriortotheneckofthemandible(approximately1.5cm
belowthezygomaticarch)whereitbifurcatestoformthemaxillaryandsuperficial
temporalarteries.Thesuperiorthyroid,lingual,andfacialarteriesarisefromtheventral
aspectneartheoriginoftheexternalcarotid;theascendingpharyngeal,occipitaland
posteriorauricularbranchesarisefromthedorsalsideoftheexternalcarotid.The8
variablebrancharteriesoftheexternalcarotidare:maxillary,superficialtemporal,
superiorthyroid,lingual,facial,ascendingpharyngeal,occipital,andposteriorauricular
arteries.
Relations
Thehypoglossalnervepasseslateralandanteriortotheexternalcarotidarteryjustabove
thelevelofthehyoidbone.Theexternalcarotidislocatedsuperficiallyandsomewhat
anteriorandmedialtotheinternalcarotidartery.Interveningbetweenthe
Page59of203
internalandexternalcarotidarteriesareseveralanatomicentities:
stylopharyngeusmuscle
styloglossusmuscle
styloidprocess
glossopharyngealnerve
pharyngealbranchesofthevagusnerve
Theanatomyofthebranchesoftheexternalcarotidarterywillbediscussedwithrelated
organs.
SURGICALAPPLICATIONSOFARTERIALANATOMY
Occasionallytheexternalcarotidarterymaybeabsentononeorbothsides.
Thebranchesofthemissingvesselsarisefromtheexternalorcommoncarotidonthe
otherside.Theinternalcarotidmaybeabsentrarely.
Thecommoncarotidmaybifurcatehighatthelevelofthehyoidbone,orloweratthe
levelofthecricoidcartilage.48
Severalnervesoftheneckarerelatedtotheinternalcarotidartery.Itisimportanttobe
awareofpotentialinjurytocranial
nervesXIIandX,especiallyduringcarotidsurgery.

Ligationoftheexternalcarotidarterycanbedonewithimpunityiftheinternalcarotid
arteryisnotinjured(Fig.138).Theligationcanbedoneaboveorbelowtheoriginofthe
superiorthyroidarteryifnecessary.
Despiteabundantcollateralcirculationofthecommoncarotidartery,unilateralligation
ofthearteryshouldneverbedone
unlessitisabsolutelynecessary,accordingtoHollinshead36(seeFig.136).Ligationof
thecommoncarotidarteryhasbeensaidtoreducethebloodflowoftheinternalcarotid
arteryand,therefore,thesupplytothebrainbyapproximately
50%.36AccordingtoRobertsetal.,49theexternalcarotidarteryalsodeliversbloodto
theinternalcarotid(byvirtueoftheanastomosesofthetwo).But,evenifthereisno
vasculardisease,itissufficientinonly50%ofthecases.Thisoccursbecauseflowtends
tobefromtheinternalcarotidtotheexternalcarotid(theoppositeofthatanticipated),
thusdivertingevenmorebloodflowfromthebrain.
Ligationoftheinternalcarotidarteryshouldbeabsolutelyavoided(Fig.138).
AccordingtoDandy,50,51therewasadeath
rateof4%followingligationoftheinternalcarotidforintracranialaneurysms.
PembertonandLivermore52reportedadeathrateof15.7%inastudyofinternalcarotid
ligationsin51casesforreasonsotherthanintracranialaneurysms.Theyalsoreported
that30%ofpatientswhohadtumorsofthecarotidbodydiedasaresultofligationofthe
internalcarotid.Drakeet
al.53reported133casesofaneurysmarisingfromtheinternalcarotidartery.Theyused
internalcarotidocclusionin131casesandcommoncarotidocclusionin2,andstatedthat
Hunterianproximalarterialocclusioncanbedonewithsafety.
FIG.138.
Page60of203
Ligationguidelines.
Kuehneetal.54foundthattheneurologicoutcomeafterinternalcarotidarteryinjuryis
enhancedbyanalgorithmbasedontheliberaluseofangiography,apredefinedsurgical
approach,andselectiveobservation.Theseauthorsalsodonotadvocateligationofthe
internalcarotidartery.Thealgorithmisasfollows:
1.Hemodynamicallystablepatientswithsuspectedinternalcarotidartery(ICA)injuries
undergoadiagnosticangiography.2.Reconstructsurgicallyaccessibleinjuriesregardless
ofneurologicstatus,withtwoexceptions:
a.NeurologicallyintactpatientswithICAocclusionaretreatedbyanticoagulationand
mildpharmacologicalhypertension.
b.Minimalnonocclusiveinjuriesaremanagednonoperativelyandfollowedupbyserial
angiographyorduplexultrasonography.
3.Heparinization,shunting,andcompletionangiographyareemployed.
InthediscussionsectionofthearticlebyKuehneetal.,54theabilitytorepairtheinternal
carotidarterywasquestionedbecauseoftherelativeinaccessibilityoftwothirdsofits
length.Theauthorsrespondedthattheyhadbeenabletorepairthemajorityofinjuries
usingstandardtechniques.
Page61of203

Thepatientwithinjuryoftheinternalcarotidarterymaydevelophemorrhagic
infarctioninthereperfusedischemicbrain,55orcerebrovascularmorbiditysuchas
cerebraledemaandherniation.54
AsreportedbyOkamoto,56theonlytherapyofferinganypotentialcureorpalliationin
advancedheadandneckcancerwithinvolvementofthecarotidarteryisresectionofthe
carotidartery.
MarienandThompson57reportacaseofananomalousoccipitalarteryoriginatingfrom
thecervicalinternalcarotidarteryandnotfromtheposteriorwalloftheexternalcarotid
artery.
Ballottaetal.58statedthatcranialandcervicalnerveinjuryaftercarotidendarterectomy
isacommonmajororminorcomplication.
Gutermanetal.59reportedthatcarotidendarterectomyforrevascularizationofthe
cervicalcarotidbifurcationprovidesagoodalternativetoopensurgeryforpatientswho
areconsideredatriskforexcessivemorbidityandmortality.
Veins
INTERNALJUGULARVEIN
Theinternaljugularvein(Fig.139)istheprincipalveinoftheheadandneck;itisthe
downwardcontinuationofthesigmoidsinus.Theveinexitstheskull,alongwithcervical
nervesIX,X,andXI,throughthejugularforamen.Untilitreachesthelevelofthe
superiorborderofthethyroidcartilage,theinternaljugularveinliestotheexternalside
oftheinternalcarotidartery.Later,ittakesapositionalongthelateralsideofthe
commoncarotidarterywithinthecarotidsheath.Finally,closetoitstermination,itis
locatedanteriortotheartery.Itislocatedunderthesternocleidomastoidmuscle.The
veinsthatemptyintotheinternaljugularveinwillbedescribedwiththerelatedorgans.
FIG.139.
Page62of203
Internaljugularvein.(ModifiedfromMontgomeryRL.HeadandNeckAnatomy:
WithClinicalCorrelations.NewYork:McGrawHill,1981;withpermission.)
EXTERNALJUGULARVEIN
Theexternaljugularveinpassesobliquelyandsuperficialtothesternocleidomastoid
muscledeeptotheplatysma.Theexternaljugularveinbeginsneartheangleofthe
mandible,atthejunctionoftheposteriordivisionoftheretromandibularveinwiththe
posteriorauricularvein.
Erbspointiswheretheexternaljugularcrossestheposteriorborderofthe
sternocleidomastoid;here,theveinisverycloselyrelatedtoseveralofthecervical
cutaneousnerves.Thegreatauricularnerveandthetransversecutaneousnerveareof
particularimportancebecauseoftheirsensorysupplytothelowerpartoftheearandthe
lowerpartofthefaceintheregionoftheangleofthemandible.Thisisalsothesiteof
theexitofcranialnerveXI.
Initscourse,theexternaljugularveincommunicateswiththeinternaljugularand
receivesanumberoftributariesintheneck,includingtransversecervicaland
suprascapularveins.Itusuallyendsbypiercingthesuperficialinvestinglayerofdeep

fasciaandjoiningthesubclavianvein,althoughitcanalsoterminateintheinternal
jugular.
Remember
Theexternaljugularveinmaybeligatedwithimpunityiftheinternaljugularveinis
intact.
Page63of203
LymphaticStructuresoftheNeck
NUMBEROFLYMPHNODES
Thereisasignificantrangeinthenumberoflymphnodesbelievedtobeintheneck.
Bailey&Loves60reportedthatthereareabout800lymphnodesinthehumanbody,
300ofwhichareintheneck.Incontrast,GraysAnatomy61reportedthattheadult
bodycontainsonly400450lymphnodes,with6070intheregionoftheheadandneck.
Carlsonstated(personalcommunicationbetweenG.W.CarlsonandJ.E.Skandalakis,
April22,1996),Therearemanylymphnodesinthefirstechelondrainageoftheoral
cavityandoropharynxthatareneversurgicallyremovedsoIfeelthatthetotalnumberof
lymphnodescouldbeapproximately150to300.
DrinkerandYoffey62wrotethatallthelymphoidtissueinthehumanbody(including
thelymphocytesinbonemarrow)probablycorrespondstonearly1%ofthetotalbody
weight.Thismayequalamasshalftheweightoftheliver.
LEVELSOFTHENODES
Theanatomyandpathologyofcervicalandretropharyngeallymphnodeshasbeen
evaluatedbycomputedtomographyby
Mancusoetal.63,64Fromasurgicalstandpoint,however,thelymphnodesoftheneck
aredividedinto5groups,orlevels.Thereisnowidespreadagreementonthe
nomenclatureoflymphnodesandtheirdivisionintogroups.Weconsiderthesystem
ofHealey65tobethebestandtheeasiesttoremember;thechainsofnodesareshown
inFig.140.ThegroupscomposingthesechainsarelistedinTable12.Someofthe
nodesoftheintermediateverticalchainareshowninFig.141.
Table12.LymphNodesandtheLymphaticDrainageoftheHeadandNeck
Lymphatics
Location
From
To
Superiorhorizontalchain:
Submentalnodes
Submentaltriangle
Skinofchin,lip,floorofmouth,tipoftongue
Submandibularnodesorjugularchain
Submandibularnodes
Submandibulartriangle
Submentalnodes,oralcavity,face,exceptforeheadandpartoflowerlip
Intermediatejugularnodes,deepposteriorcervicalnodes
Preauricular(parotid)nodes

Infrontoftragus
Lateralsurfaceofpinna,sideofscalp
Deepcervicalnodes
Postauricular(mastoid)nodes
Mastoidprocess
Temporalscalp,medialsurfaceofpinna,externalauditorymeatus
Deepcervicalnodes
Occipitalnodes
Betweenmastoidprocessandexternaloccipitalprotuberance
Backofscalp
Deepcervicalnodes
Verticalchain:
Page64of203
Posteriorcervical(posteriortriangle)nodes
Subparotidnodes,jugularchain,occipital,andmastoidarea
Supraclavicularanddeepcervicalnodes
Superficial
Alongexteriorjugularvein
Deep
Alongspinalaccessorynerve
Intermediate(jugular)nodes
Allothernodesofneck
Lymphatictrunkstoleftandrightthoracicducts
Juguloparotid(subparotid)nodes
Angleofmandible,nearparotidnodes
Jugulodigastric(subdigastric)nodes
Junctionofcommonfacialandinternaljugularveins
Palatinetonsils
Jugulocarotid(bifurcation)nodes
Bifurcationofcommoncarotidarteryclosetocarotidbody
Tongue,excepttip
Juguloomohyoid(omohyoid)nodes
Crossingofomohyoidandinternaljugularvein
Tipoftongue
Anterior(visceral)nodes
Parapharyngealnodes
Lateralandposteriorwallofpharynx
Deepfaceandesophagus
Intermediatenodes
Paralaryngealnodes
Lateralwalloflarynx
Larynxandthyroidgland
Deepcervicalnodes

Paratrachealnodes
Lateralwalloftrachea
Thyroidgland,trachea,esophagus
Deepcervicalandmediastinalnodes
Prelaryngeal(Delphian)nodes
Cricothyroidligament
Thyroidgland,pharynx
Deepcervicalnodes
Pretrachealnodes
Anteriorwalloftracheabelowisthmusofthyroidgland
Thyroidgland,trachea,esophagus
Deepcervicalandmediastinalnodes
Inferiorhorizontalchain:
Page65of203
Supraclavicularandscalenenodes
Subclaviantriangle
Axilla,thorax,verticalchain
Jugularorsubclaviantrunkstorightlymphaticductandthoracicduct
FIG.140.
ThelymphnodesoftheneckfromHealeysclassification.SH,Superiorhorizontalchain.
IH,Inferiorhorizontalchain.PV,Posteriorverticalchain.IV,Intermediateverticalchain.
AV,Anteriorverticalchain.(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.
AnatomicalComplicationsinGeneralSurgery.NewYork:McGrawHill,1983;with
permission.)
FIG.141.
Page66of203
Somedrainagetolymphnodesoftheintermediatevertical(jugular)chain.
(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.AnatomicalComplicationsin
GeneralSurgery.NewYork:McGrawHill,1983;withpermission.)
LevelI(SubmentalandSubmandibularNodes)
LevelIconsistsofalllymphnodeswithinthesubmentalandsubmandibulartriangles,
i.e.,betweentheanteriormidlineandtheanteriorborderoftheposteriorbellyofthe
digastricmuscle.
LevelII(UpperJugularChain)
Thislevelincludesalldeepjugularlymphnodesintheupperonethirdoftheneck.
Arbitrarily,thatareaisboundedbytheupperonethirdoftheposteriorborderofthe
sternocleidomastoidmuscleandthemedialborderoftheposteriorbellyofthedigastric.
Theboundaryextendsabovetotheoccipitalareaandbelowtoalinecorrespondingtothe
pathwayofthegreatauricularnerve,whereitcrossestheupperpartofthe
sternocleidomastoidobliquely.Thejugulodigastric(subdigastric)nodealsobelongsto
thislevel.

LevelIII(MidjugularChain)
Thisisaneartriangleformed(below)bytheanteriorbellyoftheomohyoidmuscle,
laterally(posteriorly)bytheposteriorborderofthemiddleonethirdofthe
sternocleidomastoidmuscle,andmediallybythehyoidbone.
LevelIV(LowerJugularChain)
TheboundariesofLevelIVconsistoftheposteriororlateralborderofthelowerthirdof
thesternocleidomastoid,superiorlyoftheomohyoidmuscle,andinferiorlyofthe
clavicle.Thejuguloomohyoidanddeeplowerjugularlymphnodesarelocatedwithinthis
space.
LevelV(PosteriorCervicalTriangle)
Thisistheposteriortriangleoftheneck,whichincludestheposteriorcervicallymph
nodesintoto(spinalaccessorynodes,inferiorhorizontalchain,scalenenodes).
Page67of203
Krausetal.66reportedasmallincidenceofsupraspinallymphnodemetastasisin
patientswithsquamouscellcarcinomaoftheoralcavityandoropharynxwithnegative
lymphnodes.
SPECIALLYMPHNODES
Virchowsnode,alsocalledthesignalnode,islocatedjustabovethemiddlethirdofthe
leftclavicle.Whensufficientlyenlargedandfirmenoughtobepalpable,itisusually
presumptiveevidenceofmalignantneoplasmbelowthediaphragm.
TheDelphiannodeisfoundjustabovethethyroidisthmus.
Theneckalsocontainsanumberofsubepitheliallymphoidstructures,thetonsils.
Tonsils
Theopeningbetweenthenasalandoralcavitiesandthepharynxisguardedbyagroupof
lymphoidstructurescollectivelyreferredtoastheringofWaldeyer(Fig.142).
FIG.142.
ThelymphoidstructuresofthetonsillarringofWaldeyersurroundingthepharynx.
(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.AnatomicalComplicationsin
GeneralSurgery.NewYork:McGrawHill,1983;withpermission.)
Ontheroofofthenasopharynx,atthesuperioraspectoftheringofWaldeyer,isthe
pharyngealtonsil(adenoids).Thelingualtonsilsareattheinferioraspectofthering,on
thesidesofthebaseofthetongue.Laterally,thepalatinetonsilsguardtheentrancetothe
pharynx.Theremaybeabandofsuperficiallymphnodules,thelateralband,betweenthe
pharyngealandpalatinetonsils.Thesetonsillarorgansdifferfromlymphnodesinthat
theyprovideoriginto,butdonotreceive,lymphatic
Page68of203
vessels;Fig.142showsthelymphnodesintowhichtheydrain.
MASSESINTHENECK
Thehumanneckisdesignedsuchthattheswellingofanormalstructureorthepresence
ofanabnormaloneisreadilyapparent.Neoplasmsandinfectionscanaffectanyofthe
6070lymphnodesorthemorethanadozenfascialspacesintheneck.Persistent
embryonicstructuresmayoccupyspacesnolongeravailabletothem.Thestructuresof

theneckarepackedsotightlythatnearlyeverylesionexpressesitselfasavisibleor
palpablebulge.Inmostcases,eventhemostperfunctoryphysicalexaminationwillreveal
theswelling.
Skandalakisetal.67examinedreportsof7,748neckmassesfoundin232,256surgical
admissionsfrom1954to1972.Ofthese,3,625wereofthyroidorigin(46.8percent)and
4,123wereofnonthyroidorigin(53.2percent).
Withalittleroundingofthefiguresintheabovestudy,tworulesbecameapparent.The
rulesofferawellmarkedpathwaytodiagnosisofnonthyroidneckmasses.
Ruleof80
TheRuleof80forNeckMassesisasfollows.80percentof:
nonthyroidmassesareneoplastic
neoplasticmassesareinmales
neoplasticmassesaremalignant
malignantmassesaremetastatic
metastaticmassesarefromprimarysitesabovetheclavicle
Ruleof7
TheRuleof7providesaprobablediagnosisoftheneckmassbasedontheaverage
durationofthepatientssymptoms.
7days:inflammation
7months:neoplasm
7years:congenitaldefect
AIDS(AcquiredImmuneDeficiencySyndrome)mayhavechangedthesenumbers,since
mostpatientswillhaveseveralothergroupsoflymphnodesinvolved,suchasaxillary
nodesandinguinalnodes.TheRuleof80andRuleof7werebasedonhospitalized
patientswithcervicallymphadenopathy.Inspiteoftheimpossibilityofsuchastatistical
analysisbeingduplicatedtoday(mostpatientswithcervicallymphadenopathyaretreated
asoutpatients),theauthorsthinkthatbothrulesremainusefulandworthremembering.
Thebestdiagnosisofprimaryormetastaticheadandneckmassesisacompleteclinical
evaluationandbiopsyorbiopsies.Lylesetal.68andFeldmanetal.69foundfineneedle
aspirationreliableandsafeinthemanagementofsquamouscell
carcinomaoftheheadandneck.Leeetal.70studiedpatientswithmetastaticsquamous
carcinomaoftheneckandoccultprimarylesion.Theyadvisedthoroughevaluationprior
tosurgerytolocatetheprimarytumors,andreportedthatsurgery,irradiation,orbothcan
cureabout50%ofpatientswithanunknownprimarytumor.
Clonalassayofheadandnecktumorswasthetopicofseveralpapersfromtheearly
1980s.WequotefromJohns:71
...Theclonogenicsoftagarassayforheadandnecktumorcellsisausefultoolfor
studyingtheirbiologyandgrowthcharacteristics...Ultrastructuralstudiesareparticularly
helpfulindelineatingthecharacteristicsoftumorstemcellsand
Page69of203
understandingthehistogenesisofneoplasms...Lowcloningefficiency(<0.005%)was
associatedwithgoodprobabilityofsurvival,whereashighcloningefficiency(0.005%)
wasassociatedwithearlyrecurrenceofcancerordeathfromthedisease.

JohnsandMills72elaboratedontherelationshipofvigorousstemcellpopulations,as
measuredbycloningefficiency,andthe
developmentofrecurrencesandmetastasesinsquamouscellcarcinomasoftheheadand
neck.Johnsetal.73reportedthatthehumancolonyformingassaytestcontributedtothe
understandingofthecellularoriginsofsalivaryglandlesionsandthechemosensitivities
ofsalivaryglandcarcinomas.
THORACICDUCT
Thethoracicductoriginatesfromthecisternachyliandterminatesintheleftsubclavian
vein.Itisfrom38to45cmlong.Theductarisesataboutthelevelofthe2ndlumbar
vertebrafromthecisternachylior,ifthecisternaisabsent(about50percentof
cases),fromthejunctionoftherightandleftlumbarlymphatictrunksandtheintestinal
lymphtrunk.74Itascendsontherightsideofthemidlineontheanteriorsurfaceofthe
bodiesofthethoracicvertebrae.Itcrossesthemidlinebetweenthe7thand5ththoracic
vertebraetolieontheleftside,totheleftoftheesophagus.
Theductpassesbehindthegreatvesselsatthelevelofthe7thcervicalvertebra,crossing
ventraltothevertebralartery,anddescendsslightlyasitpassesbehindthecommon
carotidarterytoentertheleftsubclavianvein(Fig.143)atitsjunctionwiththeleft
internaljugularvein.Theductmayhavemultipleentrancestothevein,andoneormore
ofthecontributinglymphatictrunksmayenterthesubclavianorjugularvein
independently.Itcanbeligatedwithimpunity.
FIG.143.
Thethoracicductandmainleftlymphatictrunks.Trunksarevariableandmayenterthe
veinswiththethoracicductorseparately.(ModifiedfromSkandalakisJE,GraySW,
RoweJSJr.AnatomicalComplicationsinGeneralSurgery.NewYork:McGrawHill,
1983;withpermission.)
Thethoracicductcollectslymphfromtheentirebodybelowthediaphragm,aswellas
frommuchoftheleftsideofthethorax.Lymphnodesmaybepresentatthecaudalend,
buttherearenonealongitsupwardcourse.Injurytotheductinsupraclavicularlymph
nodedissectionsresultsincopiouslymphorrhea,depletionofbodyfluids,andlossof
proteinsandelectrolytes.Ligationistheanswer.
Wechselbergeretal.75advocatethetreatmentofchronicthoracicductfistulausinga
sternocleidomastoidmuscleflap.
Page70of203
RIGHTLYMPHATICDUCT
Therightlymphaticductavariablestructureabout1cmlongisformedbytheright
jugular,transversecervical,internalmammary,andmediastinallymphatictrunks(Fig.1
44).Ifthesetrunksentertheveinsseparately,thereisnorightlymphaticduct.When
present,therightlymphaticductentersthesuperiorsurfaceoftherightsubclavianveinat
itsjunctionwiththerightinternaljugularvein.Itdrainstherightsideofthehead,right
upperlimb,mostoftherightsideofthethorax,andthelowertwothirdsoftheleftlung.
Itistheremnantoftheoriginalembryonicsystemofbilaterallysymmetricrightandleft
thoracicducts,representingtheterminalpartoftherightthoracicduct.
FIG.144.

Therightlymphaticductisformedbythejunctionofseverallymphatictrunks.Ifthey
entertheveinsseparately,theremaybenorightlymphaticduct.(Modifiedfrom
SkandalakisJE,GraySW,RoweJSJr.AnatomicalComplicationsinGeneralSurgery.
NewYork:McGrawHill,1983;withpermission.)
NervesoftheNeck
Althoughtheinnervationofsomeoftheanatomicentitiesoftheneckisdescribedin
detailinthischapter,wethinkitisappropriateheretopresentabriefsummaryofthe
nervesingeneral.
Thenervesoftheneckformapeculiarpathwayfromabovedownward,travelingallover
theneckbutwithadefiniteanatomicdestinytosupplythevesselsofthehead,
intracranialarea,neck,andupperextremities.Thenervesthatareresponsibleforthe
innervationofsomeanatomicentitiesintheneckorotherterritories,butoriginatingin
theneck,areasfollows:
5cranialnerves(VII,IX,X,XI,XII)
cervicalsympatheticnerves
cervicalplexus(superficialanddeep)brachialplexus
FiveCranialNerves
Thecranialnerves(VII,IX,X,XI,XII)arecoveredindetailinseveralpartsofthisbook,
suchasthesectiononparotidglandsinthischapter(facialnerve),inthethyroidsection
ofthischapterandinthestomachchapter(vagusnerve),andseveralother
Page71of203
nervesarecoveredinthediscussionofanatomiccomplicationsofsurgeryfor
metastaticdiseaseoftheneckinthesectiononradicalneckdissection.Theemphasis
herewillbeonthetopographyofthegangliaofthesympatheticchainandtheirbranches,
ratherthanondetailsoftheactionofthissystem.Eventhoughknowledgeofthesystem
hasincreased,thereisstill
muchwedonotknow.PerhapsSirWilliamTurnerwasrightwhenhestated,The
sympatheticbeginsnowhere.76
CervicalSympatheticNerves
Thesympathetictrunkoftheneckisintheprevertebralfasciabetweenthecarotidsheath
infrontandthelonguscolliandlonguscapitismusclesbehind.Itextendsaboveintothe
skullasaplexussurroundingtheinternalcarotidartery.Itiscontinuous,downward,with
thesympathetictrunkofthethorax.
Thecervicalsympatheticchainisformedbythreeganglia(superior,middle,andinferior)
(Fig.145).Eachgivesgreyramicommunicantestothecervicalnerves,acardiacnerve,
andaplexustoanartery.
FIG.145.
Thecervicalsympathetictrunk.(ModifiedfromDeckerGAG,DuPlessisDJ(eds).Lee
McGregorsSynopsisofSurgicalAnatomy(12thed).Bristol,England:JohnWright,
1986;withpermission.)
Theuppermostganglion,thesuperiorcervicalganglion,isareddish,flat,ellipsoidal
structure.Itisthelargestofthethreegangliaandislocatedjustbehindthesheathofthe
internalcarotidartery.Theganglionrestsontheprevertebralfasciaintheareaofthe

transverseprocessofthe2ndand3rdcervicalvertebrae.Thefasciacoversthelongus
capitismuscle.
Page72of203
Thesuperiorsympatheticganglionoftheneckgivesgreyramicommunicantestothe
firstcervicalnerves(1to4),formsaplexusaroundtheexternalcarotidartery,givesa
branchtothepharyngealplexus,andfinallygivesorigintothesuperior
cardiacnerveandthecarotidnerve.McGregorandDuPlessis76statedthattheplexus
aroundtheinternalcarotidarterycommunicateswiththevagus,glossopharyngeal,and
hypoglossalnerves.
Topographicallythemiddlecervicalganglion,whichisthesmallestofthethree(about3
mmindiameter),islocatedatthelevelofthe6thcervicalvertebraandthecricoid
cartilage.Theinferiorthyroidarteryisanexcellentlandmarkforthetopographyofthis
ganglionwhichislocatedanteriororposteriortotheartery.WeagreewithMcGregor
andDuPlessisthatitisalwayspresent.
Themiddlecervicalgangliongivesgreyramicommunicantestothe5thand6thcervical
nerves,aplexusaroundtheinferiorthyroidartery,andthemiddlecardiacnerve.Itis
interconnectedtotheinferiorcervicalganglion.
Theinferiorcervicalganglion(cervicothoracicorstellate)issituatedbehindthevertebral
artery,andbetweenthetransverseprocessofthe7thcervicalvertebraandtheneckofthe
1strib,andmedialtothedescendingbranchofthecostocervicalbranchofthesubclavian
artery.Itislargerthanthemiddleganglionbutsmallerthanthesuperiorcervical
ganglion.ItgivesgreyramicommunicantestoC7C8cervicalnerves;itsurroundsasa
plexusthesubclavianarteryanditsbranches,anditgivesorigintotheinferiorcardiac
nerve.The1stthoracicandinferiorsympatheticgangliaareoftenunitedtoformthe
stellateganglion.
Klineetal.27discussedthetopographicanatomyofthestellateganglion:
AnsaeorsmallrootletsenterandleaveT1andcanleadthesurgeontothestellate
ganglionandthenthecaudalportionofthethoracicsympatheticchain.Anotherlandmark
isthevertebralartery,whichcanbefoundoriginatingfromtheproximalportionofthe
subclavianandrunningupwardandmediallytowardthetranverseprocessesofC6.By
elevationoftheproximalportionofthevertebralartery,thestellateganglioncanusually
befoundposteriortoit;therestofthethoracicsympatheticchaincanbefoundinferiorto
itbeneathsubclavianvesselsandintheuppermediastinum.
SURGICALAPPLICATIONS
Remember
Thenodoseganglion(ganglioninferius)ofthevagusnerveisclosetothesuperior
cervicalganglion.AnsonandMcVay77statedthattheganglionshouldnotbeexcised
unlessitssympatheticcommunicatingstrandleadstothemiddlecervicalganglion;this
preventsmistakingitforthenodoseganglionofthevagusnerve.
Whenthestellateganglion(ganglioncervicothoracicum)isremoveditproduces
Hornerssyndrome(seeAnatomicComplicationsofThyroidectomy).Toavoid
Hornerssyndrome,carefullydissecttheinferiorpartofthestellateganglion.77

Removalofthestellateganglionaswellasthe1st,2nd,3rd,andmaybethe4ththoracic
ganglia(cervicodorsalsympathectomy)isdoneoccasionallyforsevereReynauds
phenomena(vasospasticdiseaseoftheupperextremityandseverepalmarhyperhidrosis)
inthehopethatthepainsecondarytothevascularspasmwillbealleviated.
Lowanteriorcervical,transaxillary,ortranspleuralthoracoscopicapproachmaybeused
forcervicodorsalsympathectomy.
Theupperpathwayofthephrenicnerveisalandmarkforthelocationofthe5thand6th
cervicalnervesduringneckexploration.
Thecervicalsympatheticchainislocatedlateraltotheanteriorspinalligament.
Occasionally,thethorascopistconfusestheligamentwiththechain,andwillnotperform
acervicalsympathectomy.ThenerveofKuntzisahighlyvariableanatomicentitywithin
theupperthorax.Itislocatedbetweentherootofthefirstthoracicandthesecond
thoracicintercostalnerves.
Thephysiologicactionofthisramusmayrelatetothesympatheticchain.78,79
Page73of203
CervicalPlexus
Thecervicalplexus(Fig.146)isformedbytheanteriordivisionsofthespinalnerves
C1C4andislocatedbetweenthemiddlescalenusmuscleandthelevatorscapula.Itis
coveredbytheSCMmuscle.Thebranchesofthecervicalplexusconsistoftwogroups:
superficialanddeep.
FIG.146.
Superficialanddeepcervicalplexuses.(ModifiedfromHealeyJEJr,HodgeJ.Surgical
Anatomy.Philadelphia:BCDecker,1990;withpermission.)
Thesuperficialgroup(Fig.147)isformedbytheanteriorprimarydivisionsofcervical
nervesC2,C3,andC4.Thephysiologicdestinyofthisgroupissensory.Thefollowing
nervesbelongtothesuperficialgroupandallofthemwillbeseeninthevicinityofthe
middlepartoftheposteriorborderoftheSCMmuscle,atwhichpointthesuperficial
plexusexits.
lesseroccipital(C2)
greatauricular(C2,C3)
transversecervical(C2,C3)supraclavicular(C3,C4)
FIG.147.
Page74of203
Superficialgroupofthecervicalplexus.(ModifiedfromHealeyJEJr,HodgeJ.
SurgicalAnatomy.Philadelphia:BCDecker,1990;withpermission.)
Thedeepgroup(Figs.146,148)ismotor,innervatingthestrapmusclesoftheneckand
theskinanddiaphragm.ThebranchesareformedbytheanteriordivisionsofC1C4
nerves.Thedeepgroupconsistsofthefollowingnerves:
phrenic(C3C5)
muscularbranchestostrapmuscles:omohyoid,sternohyoid,sternothyroid,thyrohyoid
bywayoftheansacervicalis(C1,C2,andC3)
geniohyoid(C1)

rectuscapitislateralis(C1)rectuscapitisanterior(C1)longuscapitis(C1C4)
longuscolli(C3C8)
Page75of203
scalenusanterior(C4C6)
intertransversalis(C1C8)
sternomastoid(C2,C3,orboth)
levatorscapulae(C3C4)
trapezius(C3C4probablyproprioceptive,withmotorsupplyfromXI)scalenus
medius(C3C7)
FIG.148.
Deepgroupofthecervicalplexus.(ModifiedfromHealeyJEJr,HodgeJ.Surgical
Anatomy.Philadelphia:BCDecker,1990;withpermission.)
BrachialPlexus
Page76of203
Thebrachialplexusisformedbytheanteriordivisionsofthefourlowercervical
nerves(C5C8)withparticipationoftheoneupperthoracicnerve(T1)(Fig.149).In
addition,communicationsfromC4andT2mayalsobepresent.Itisanerveplexus
formed,subsequently,ofroots,trunks,divisions,cords,andterminalnervebranches.The
brachialplexusemergesfrombetweentheanteriorandmiddlescalenemuscles,resting
uponthemiddlescalene.Therootsandtrunksarelocatedintheneckandarerelatedto
thesubclavianartery.Tobemorespecifictheplexusisintheposteriortriangleofthe
neck:itisadjacenttotheclavicle,sternocleidomastoidmuscle,andanteriorscalene
muscle;itrestsonthemiddlescalenemuscle.
FIG.149.
Schemaofthebrachialplexus.
Asthenervesoftheplexusemergefrombetweentheanteriorandmiddlescalene
musclestheybecomeensheathedwiththeprevertebralfasciacoveringthemuscles.This
connectivetissueinvestmentbecomestheaxillarysheathwhichcanbeinjectedwith
anestheticinsurgicalproceduresoftheupperlimb.
SURGICALAPPLICATIONS
Thebrachialplexusintheneckmaybepalpableinanangleformedbetweenthe
clavicleandthelowerlateralborderof
Page77of203
theSCMmuscle.
Thebrachialplexusintheneckisrelatedtothefollowinganatomicentitiesfrom
superficialtodeep:
Anteriorskin
superficialfasciaandplatysma
branchesofsupraclavicularnerves
deepfascia(roofofposteriortriangle)
externaljugularveinandsomeofitstributariesomohyoid:posteriorbelly

transversecervicalartery
nervetosubclaviusmuscle
thirdpartofsubclavianarteryinfrontofthelowesttrunksuprascapularartery
clavicle
Posterior
middlescalenemusclelongthoracicnerve
Inferior
Thelowesttrunkliesonthefirstrib,markingit,sandwichedbetweenthesubclavian
arteryinfrontandthemiddlescalenebehind.
Thedorsalscapulararteryoften(50%)passesbetweenthetrunksoftheplexus.
Platzer80categorizestheinjuriesofthebrachialplexusintoupperandlowerdivisions.
InjurytotheupperplexuscancauseDuchenneErbparalysisinvolvingmovementsofthe
shoulderjointduetoinjuriesoftherootsofC5andC6andwithsecondaryinvolvement
oftheabductors,lateralrotatorsoftheshoulderjoint,andflexorsoftheelbowjointand
supinatormuscle.Theremaybesomedisturbanceofsensibilityattheshoulderandatthe
radialsideoftheforearm.
Erbspoint(Figs.150,151)isthejunctionofseveralnerves.Heretheuppertrunkof
thebrachialplexusisformedbytheunionofthe5thand6throotsofthebrachialplexus.
Thisveryshortuppertrunkbifurcatesforminganteriorandposteriordivisions.The
suprascapularandsubclaviannervesaredirectbranchesfromtheuppertrunkjustbeyond
Erbspoint.
FIG.150.
Page78of203
Schemaoftheformationofthebrachialplexus,anditsbranchesintheneck.The
twigstothelongusandscalenemusclesarenotshown.
FIG.151.
Page79of203
ThedottedcircleisErbspoint.Meetingarethefollowingnerves:AandB,thefifth
andsixthrootsofthebrachialplexusgoingtoformC,theuppertrunkofthebrachial
plexus;DandE,anteriorandposteriordivisionsoftheuppertrunk;F,suprascapular
nerve;G,nervetosubclaviusmuscle.
IftheuppertrunkatErbspointisstretchedortornduringthebirthofachild,Erbs
paralysisoftheupperarmmayresult.
ErbspointislocatedjustbehindtheposteriorborderoftheSCMmuscle,
approximately23cmabovetheclavicle,inthevicinityofthetransverseprocessofthe
6thcervicalvertebra.
Inaslenderpersonwithminimaladiposetissueintheneck,thesupraclavicularnerveof
thecervicalplexuscanbepalpated.
IsolatedinjuriesoftheC7middletrunkareunusual,butwhentheyoccur,adductionand
medialrotationoftheupperlimbareweakened,andextensionoftheelbowand
metacarpophalangealjointmaybelost.Thetricepsreflexdisappears.

Inthelowerplexus,traumatotherootsofC8andT1mayleadtoimpairmentofthe
longflexorsofthefingers,theshortmusclesofthehand,andlossofsensibilitiesatthe
ulnarsideofthehandandforearm(DejerineKlumpkeparalysis).
ThyroidGland
EmbryogenesisNormalDevelopment
Thethyroidglandappearsbytheendofthethirdweekasanepithelialthickeningofthe
floorofthepharynxatthelevelofthefirstpharyngealpouch.This,thelargemedian
thyroidanlage,maybeadiverticulumorasolidbud.Cranialgrowthofthetongue,
togetherwithelongationoftheembryo,carriestheoriginofthethyroidglandfarcranial
totheglanditself.Thesiteofthisoriginistheforamencecumoftheadulttongue.In
someindividualsitisnotgrosslyvisible.
Page80of203
Thethyroidglandremainsconnectedwiththeforamencecumbyaminute,solid
thyroglossalductthatpassesthrough,oranteriorto,thehyoidbone.Bythefifthweekof
gestation,thisductusuallybecomesfragmented;persistenceofanyportionisnot
unusual.Inabout50percentofthepopulation,theductcanbetraceddistallytothe
pyramidallobeofthethyroidgland(Fig.152).
FIG.152.
Normalvestigesofthyroidglanddevelopment.Noneareofclinicalsignificance,buttheir
presencemaybeofconcerntothesurgeon.(ModifiedfromSkandalakisJE,GraySW,
RoweJSJr.AnatomicalComplicationsinGeneralSurgery.NewYork:McGrawHill,
1983;withpermission.)
Thedevelopinggland,atfirstanirregularplate,developstwolateralwingsconnectedby
theisthmus.Folliclesappearduringthesecondmonthofgestationandincreasethrough
thefourthmonth.Colloidformationanduptakeofradioactiveiodinebeginataboutthe
eleventhweek.
Epithelialstructures,thepairedlateralanlages,areformedfromtheventralportionsof
thefourthandfifthbranchialpouches.Thisstructure,thewellknownultimobranchial
body(caudalpharyngealpouchcomplex),becomeslostinthedevelopingthyroidgland,
anditscellsbecomedispersedastheC(calcitonin)cellsamongthethyroidfollicles.
Presentevidencesuggeststhattheprimaryoriginofthecalcitoninproducingcellsofthe
thyroidglandistheneuralcrestofthe
embryo.Fromtheneuralcrestthesecellsmigratetotheultimobranchialbody,81and
laterbecomepartofthethyroidgland.Ccellsbelongtoagroupofneuralcrest
derivativesknownasAPUD(amineprecursoruptakeanddecarboxylation)cells.
Welbourn82believedthattumorsofthesecells,medullarycarcinomas,accountfor6to8
percentofallthyroidmalignancies.Severalotherendocrineproducingcellsinthegut
andtrachealwalls,pancreas,andadrenalglandsbelongtotheAPUDsystem.Tumorsof
theAPUDsystemarecollectivelycalledapudomas.
CongenitalAnomalies
Itisnotwithinthescopeofthisbooktopresentdetailedanomaliesorvariationsofthe
thyroidgland.Thestudentofthyroid
Page81of203

anatomywillfindcompletecoverageinEmbryologyforSurgeons.83
However,wewillmentionafewcommonanomaliesanddiscussingreaterdetailthe
lateralaberrantthyroid.
TheanatomyoftheabnormalisshowninTable13.
Table13.AClassificationofCongenitalAnomaliesoftheThyroidGlanda
BothMedianandLateralAnlages
MedianAnlage
LateralAnlage
NeitherAnlage
A.Variableshapeandweight
A.Agenesis
A.Nonfusionwithmediananlage
A.Vessels
B.Symmetry
1.Isthmus:thick,thin,absent
B.Cystswithsquamousepitheliallining
1.Artery
C.Totalthyroidagenesis
2.Bilobedpartial
C.Solidcellrests:Ccells
2.Vein
D.Onelobeabsent
3.Unilateral
D.Agenesis:LobdellDiGeorgesyndrome
3.Lymph
E.Pyramidallobe
4.Pyramidallobe
E.Pharyngealpouchesremnants
B.Muscles
1.Absent
5.Short
1.Thymic
C.Nerves
2.Fromtherightlobe
6.Long
2.Parathyroid
3.Fromtheleftlobe
7.RightorLeft
3.Ultimobranchialbody
4.Fromtheisthmus
8.Thyroglossalduct
F.Ectopicthyroidtissueinfat,muscles
B.Anomaliesofdescentalongthethyroidline

G.Fat,musclecartilagewithinthethyroidgland
1.Lingual
H.Lateralaberrantthyroidnotwithinthecapsuleofmediallylocatedlymphnodes
2.Sublingual
3.Prelaryngeal
C.Accessoryectopic(i.e.,outsidethepathwayof
descent)
Page82of203
1.Mediastinal
2.Intratracheal
3.Lateraltojugular
4.Ovarian
5.Sellaturcica
6.Retrotracheal
7.Preaortic
8.Pericardial
9.Cardiac
10.Portahepatis
11.Gallbladder
12.Groin
13.Intralaryngeal
14.Intraesophageal
15.Intralymphnode
aThisclassificationisbasedonthethyroidanlage(s),ifany,involvingthe
anomaly.
Source:SkandalakisJE,GraySW(eds).EmbryologyforSurgeons,2ndEd.Baltimore:
Williams&Wilkins,1994;withpermission.
LingualThyroid
Occasionallythethyroidglandisnotinthenormalcervicalposition,butliesbeneaththe
epitheliumofthetongue,atthesiteof
theforamencecum.LiVolsi84statedthatlingualthyroid(Fig.153)resultsfromafailure
ofthemediananlagetodescendfromthepharynx.
FIG.153.
Page83of203
Theembryonicpathofdescentofthethyroidgland.Anectopicthyroidmayremain
atitsleveloforigininthetongue,oritsdescentmaybeinterruptedatanypointalongthe
pathway.Hyperdescentintothethorax(primarilyretrosternalthyroid)isalsopossible.
(ModifiedfromGraySW,SkandalakisJE,AkinJTJr.Embryologicalconsiderationsof
thyroidsurgery:Developmentalanatomyofthethyroid,parathyroid,andtherecurrent
laryngealnerve.AmSurg1976;42:621628;withpermission.)

Thelingualthyroidglandisusuallysmallbutnormalandistheonlythyroidtissue
present.Radioactiveiodinescintigraphywillaidinthediagnosisandwilldeterminethe
presenceofotherthyroidtissueinthepatient.
Athyroidglandmaybefoundanywherealongthetrackfromtheforamencecumtothe
normalsite.Suchpartiallydescendedglandsarerare.85
Totalexcisionofalingualthyroidisnecessary.Itrequirescare,becausetheglandiswell
vascularizedbythelingualarteries.In
oneseries,862outof12lingualthyroidsweremalignant.Ifnomalignancyisreported
fromfrozensections,theexcisedtissuecanbeimplantedintotheanteriorabdominal
wall.
EditorialCommentOnlyrarelyissurgicalexcisionofalingualthyroidnecessary.The
naturalhistoryoflingualthyroid,aswithotherundescendedthyroidtissue,isfor
hypothyroidismtodevelopasthechildgrowsandthephysiologicdemandforthyroid
hormoneincreases.Theusualtreatmentforlingualthyroidisreplacementthyroid
hormone,whichwillsuppressTSHandallowthelingualthyroidtoregress.Sincethe
naturalhistoryoflingualthyroidisforhypothyroidismtodevelop,Iverymuchdoubt
thattransplantedlingualthyroidwouldprovideenoughthyroidhormonetoobviatethe
needforhormonereplacementtherapy.(RogerS.Foster,Jr.,MD)
PersistentRemnantsoftheThyroglossalDuct
Theforamencecumofthetongueandthepyramidallobeofthethyroidglandarenormal
remnantsofthethyroglossalduct.
Thyroglossalductcystsaccountfor62.8percentofallthecongenitalmassesofthe
neck.87Ofthose,accordingtoLiVolsi,88upto62percentcontainectopicthyroidtissue.
Primarycarcinomainthyroglossalductcystoccursinlessthan1percentof
Page84of203
cases.89,90WaltonandKoch91presentedacaseofthyroglossalductcystwith
papillarycarcinoma,andindicatedthatfewerthan150caseshavebeenreported.Table1
4showshistologiccompositionandothercharacteristicsofthyroglossalductassociated
carcinomain109cases.Medullarythyroidcancerhasnotbeenreportedbecausethereare
noCcellsinthepyramidallobe(theparafollicularCcellsarisefromthelateralthyroid
anlage).Embryologyandpathologyareinfullagreementhere.
Table14.ReportedCasesofThyroglossalDuctAssociatedCarcinomaa
Histology:
Papillarycarcinoma
99
Adenocarcinoma
2
Malignantstruma
1
Squamouscellscarcinoma
7
Total(reportedcases)
109

Female/Male
66:42(1unknown)
Age
6to81years
Historyofneckradiation
3
aAdaptedfromLiVolsiVA.SurgicalPathologyoftheThyroid.Philadelphia:WB
Saunders,1990.
Source:SkandalakisJE,GraySW(eds).EmbryologyforSurgeons,2ndEd.Baltimore:
Williams&Wilkins,1994;withpermission.
Frequently,individualswhohaveectopicthyroidalsohaveanabsenceofnormal
thyroid.Therefore,beforetheectopicthyroidisexcised,itisimportanttoevaluate
whetheritistheonlythyroidtissueinthebody.92
Betweentheforamencecumandthepyramidallobeisaverysmallepithelialtube,
usuallybrokeninseveralplaces.Occasionallytheseepithelialfragmentshypertrophy,
secretefluid,andformcysts.Drainageoraspirationofthesecystsisfutileandoften
resultsintheformationofafistula,whichusuallybecomesinfected.
Allfragmentsoftheduct,foramencecum,andmidportionofthehyoidboneshouldbe
removed(Sistrunkprocedure).Recurrenceofthecystistheresultoffailuretoremove
theentireduct.Failuretoremovethecentralportionofthehyoidbone
resultedin17percentrecurrenceinoneseriesofoperations.93Nonerve,bloodvessel,or
organneedbeinjuredinthisprocedure.Quigleyetal.94warnedagainstinadvertent
removalofapartiallydescendedthyroidglandmistakenfora
thyroglossalductcyst.
AccessoryEctopicThyroidTissue
Figure154demonstratesnotonlythepossiblesitesofectopictissuebutalsotissuesof
otheranatomicentitieswithinthe
Page85of203
thyroidparenchyma.
FIG.154.
Leftsideofdrawingillustratespossiblesitesofaccessoryectopicthyroidtissue.Right
sideofillustrationlistsotheranatomicentitiesfromwhichtissuemaybefoundwithinthe
thyroid.(ModifiedfromSkandalakisJE,GraySW.EmbryologyforSurgeons(2nded).
Baltimore:Williams&Wilkins,1994;withpermission.)
Bhatnagaretal.95describedanaccessorylobeofthethyroidglandlocatedinferiorto
bothlaterallobesandtheisthmus.Itsarterialsupplyoriginatedfromtherightinferior
thyroidarteryanditsveindrainedviatheplexusthyroideusimpar.
MonchikandMaterazzi96advisedthatposteriororaberrantmediastinalthyroidmasses
mayrequireathoracicsurgicalapproach.
Kumaretal.97reportedanadolescentwithdualectopicthyroidglandslocatedinthe
sublingualandsubhyoidregions,theseventhsuchcaseintheliterature.
LATERALABERRANTTHYROID

Ofspecialinterestandavexationtosurgeon,pathologist,andpatientislateral
aberrantthyroidtissue;thatis,tissuelocatedlateraltothejugularvein.98Ithasthree
morphologicmanifestations.
Thistissuemaybefoundasanoduleattachedbyconnectivetissuetothemothergland.
Thesethyroidtissueislands,whichpullawayfromthevisceralbodyduring
development,areneverthelessnormal.
Page86of203
Thesecondsiteforlateralthyroidtissueiswithinlymphnodesortheirremnants.We
shouldconsideracervicallymphnodecontainingthyroidfolliclestobeclinicallya
metastaticthyroidcarcinoma.However,theexistenceofheterotopicthyroidtissuewithin
cervicalglandshasbeenreported.Sixsuchcasesofnormalthyroidglandat5Im
sectionsweredescribedbySawickietal.99
Thefinalmorphologicexpressionoflaterallyaberrantthyroidtissuemustbetermed
congenital.Rubenfeldetal.100reportedapatientwhoseonlythyroidtissue,byall
appearances,waslateralaberrantthyroidtissue.
Alwaysconsiderthepossibilityofmetastaticthyroidcanceroflateralaberrantthyroid
nodules.
STRUMAOVARII
Strumaovarii,theovarianthyroid,isanextraordinarythyroidectopia,althoughitis
unrelatedtotheanatomicthyroidglandandisnotatruecongenitalanomaly.Ovarian
thyroidtissueisafellowtravellerwithdermoidcystsandteratoma.Accordingto
estimatesofWoodruffetal.,101strumaovariimayexistin0.21.3%ofallovarian
tumors.Ofthese,56%arebilateralandabout5%possessfunctioningthyroidtissue.
Kempersetal.102foundhyperthyroidisminstrumaovarii.Malignancyisapossible
occurrenceinasmanyas5%ofallstrumaovarii,103withmetastasisnotedinpapillary
carcinoma.98,104
SurgicalAnatomyGeneralTopography
Thethyroidglandconsiststypicallyoftwolobes,aconnectingisthmus,andanascending
pyramidallobe.Onelobe,usuallytheright,maybesmallerthantheother(7percent)or
mayevenbecompletelyabsent(1.7percent).Theisthmusisabsentinabout10percent
ofthyroidglands,andthepyramidallobeisabsentinabout50percent(seeFig.152).A
minuteepithelialtubeorfibrouscord,thethyroglossalduct,almostalwaysextends
betweenthethyroidglandandtheforamencecumofthetongue.
Thethyroidglandnormallyextendsfromthelevelofthe5thcervicalvertebratothebody
ofthe1stthoracicvertebra.Itmayliehigher(lingualthyroid),butrarelylower.105
Thenormalthyroidglandweighsabout30gintheadultsomewhatmoreinfemales
thaninmales.Eachlobeisapproximately
5cminlength,3cmatitsgreatestwidth,and23cmthick.106Theisthmusconnecting
thetwolobesisabout1.3cminbreadth.Thelobeshaveabroadlowerportionanda
relativelyconicalapex.
CapsuleoftheThyroidGland

Likemanyotherorgans,thethyroidglandhasaconnectivetissuecapsulewhichis
continuouswiththesepta,andwhichmakesupthestromaoftheorgan.Thisisthetrue
capsuleofthethyroid.
Externaltothetruecapsuleisawelldeveloped(toalesserorgreaterdegree)layerof
fasciaderivedfromthepretrachealfascia.Thisisthefalsecapsule,alsocalledthe
perithyroidsheathorsurgicalcapsule.Anteriorlyandlaterallythisfasciaiswell
developed;posteriorlyitisthinandloose,permittingenlargementofthethyroidgland
posteriorly.Thereisathickeningofthefasciathatfixesthebackofeachlobetothe
cricoidcartilage.SuchthickeningsaretheligamentsofBerry.Thefalsecapsule,or
fascia,isnotremovedwiththeglandduringthyroidectomy.
Thesuperiorparathyroidglandsnormallyliebetweenthetruecapsuleofthethyroidand
thefascialfalsecapsule.Theinferiorparathyroidsmaybebetweenthetrueandfalse
capsules,withinthethyroidparenchyma,orlyingontheoutersurfaceofthefascia.The
levatormuscleofthethyroidisoneormoremuscularslipsthatoccasionallyconnectthe
hyoidbonewiththethyroidgland.Thesevestigialmusclesareinconstantinoccurrence,
location,andinnervation.Theyhavebeendividedintoanterior,lateral,andposterior
levators.
VascularSupply
Page87of203
Thethyroidglandcompeteswiththeadrenalglandsforhavingthegreatestblood
supplypergramoftissue.107Oneconsequenceisthathemostasisisamajorproblemof
thyroidsurgery,especiallyinpatientswithtoxicgoiter.
Arteries
Twopairedarteries,thesuperiorandinferiorthyroidarteries,andaninconstantmidline
vessel,thethyroidimaartery,supplythethyroid(Fig.155).
FIG.155.
Thearterialsupplytothethyroidgland.Thethyroidimaarteryisonlyoccasionally
present.(ModifiedfromTzinasS,DrouliasC,HarlaftisN,AkinJTJr,GraySW,
SkandalakisJE.Vascularpatternsofthethyroidgland.AmSurg1976;42:639644;with
permission.)
SUPERIORTHYROIDARTERY
Thesuperiorthyroidarteryarisesfromtheexternalcarotidarteryjustabove,at,orjust
belowthebifurcationofthecommoncarotidartery.Itpassesdownwardandanteriorlyto
reachthesuperiorpoleofthethyroidgland.Inpartofitscourse,thearteryparallelsthe
externalbranchofthesuperiorlaryngealnervewhichsuppliesthecricothyroidmuscle
andthecricopharyngeusmuscle,thelowestvoluntarypartofthepharyngealmusculature.
Therearesixbranchesofthesuperiorthyroidartery(Fig.156):theinfrahyoid,
sternocleidomastoid,superiorlaryngeal,cricothyroid,inferiorpharyngealconstrictor,and
terminalbranchesofthearteryforthebloodsupplyofthethyroidandparathyroidglands.
Usuallytherearetwobranchestothethyroidtheanteriorandposteriorbut
occasionallytheremaybeathird,thesocalledlateralbranch(Fig.156).
FIG.156.
Page88of203

Branchesofthesuperiorthyroidartery.(ModifiedfromMontgomeryRL.Headand
NeckAnatomy:WithClinicalCorrelations.NewYork:McGrawHill,1981;with
permission.)
Atthesuperiorpole,thesuperiorthyroidarterydividesintoanteriorandposterior
branches.Theanteriorbranchanastomoses
withthecontralateralartery;108theposteriorbranchanastomoseswithbranchesofthe
inferiorthyroidartery.Fromtheposteriorbranch,asmallparathyroidarterypassestothe
superiorparathyroidgland.
InastudyofthyroidglandsremovedatautopsyfromJapanesepatients,Noborietal.109
observedthatananastomosingvesselfromtheposteriorbranchofthesuperiorthyroid
arterysuppliedthesuperiorparathyroidin45%ofcases.Themajorityof92glands
(67%)hadasinglearteryofsupply;1/3hadtwoormoresmallvesselswhichenteredthe
gland.Inthephotographsofthespecimens,thebranchingpatternoftheprimaryvessel
supplyingtheglandappearedtoindicatethatitsoriginwasfromthesuperiorthyroid
artery.
Weiglein110reportedararevariationofbloodsupplytothethyroidgland.Inthiscase,
therightinferiorthyroidarterywasreplacedbyanarteryoriginatingfromtheright
internalthoracicartery.Theleftinferiorthyroidarterywasreplacedbyanarteryarising
fromthevertebralartery.
Page89of203
INFERIORTHYROIDARTERY
Theinferiorthyroidarteryusuallyarisesfromthethyrocervicaltrunk,butinabout15
percentofindividualsitarisesdirectlyfrom
thesubclavianartery.111Theinferiorthyroidarteryascendsbehindthecarotidarteryand
theinternaljugularvein,passingmediallyandposteriorlyontheanteriorsurfaceofthe
longuscolimuscle.Afterpiercingtheprevertebralfascia,thearterydividesintotwoor
morebranchesasitcrossestheascendingrecurrentlaryngealnerve.
Therecurrentlaryngealnervemaypassanteriororposteriortotheartery,orbetweenits
branches(Fig.157).Thelowestbranchsendsatwigtotheinferiorparathyroidglandand
suppliesthelowerpoleofthethyroidgland.Theupperbranchsuppliestheposterior
surfaceofthegland,usuallyanastomosingwithadescendingbranchofthesuperior
thyroidartery.Ontheright,theinferiorthyroidarteryisabsentinabout2percentof
individuals.Ontheleft,itisabsentinabout5percent(Huntet
al.).112Thearteryisoccasionallydouble.113FIG.157.
Relationsatthecrossingoftherecurrentlaryngealnerveandtheinferiorthyroidartery.
AC,Commonvariations.TheirfrequenciesaregiveninTable19.D,Anonrecurrent
nerveisnotrelatedtotheinferiorthyroidartery.E,Thenerveloopsbeneaththeartery.
(ModifiedfromTzinasS,DrouliasC,HarlaftisN,AkinJTJr,GraySW,SkandalakisJE.
Vascularpatternsofthethyroidgland.AmSurg1976;42:639644;withpermission.)
THYROIDIMAARTERY
Thethyroidimaarteryisunpairedandinconstant.Itarisesfromthebrachiocephalic
artery,therightcommoncarotidartery,or

theaorticarch.Itoccursinabout10percentofindividuals,accordingtoMontgomery.41
Itmaybeaslargeasaninferiorthyroidarteryoritmaybeameretwig.Itsposition
anteriortothetracheamakesitimportantintracheostomy.
Page90of203
Veins
Veinsofthethyroidglandformaplexusofvesselslyinginthesubstanceandonthe
surfaceofthegland.Theplexusisdrainedbythreepairsofveins,thesuperior,middle,
andinferiorthyroidveins(Fig.158).
FIG.158.
Thevenousdrainageofthethyroidgland.Theinferiorthyroidveinsarequitevariable.
(ModifiedfromTzinasS,DrouliasC,HarlaftisN,AkinJTJr,GraySW,SkandalakisJE.
Vascularpatternsofthethyroidgland.AmSurg1976;42:639644;withpermission.)
SUPERIORTHYROIDVEIN
Thesuperiorthyroidveinaccompaniesthesuperiorthyroidartery.Emergingfromthe
superiorpoleofthethyroid,theveinpassessuperiorlyandlaterallyacrosstheomohyoid
muscleandthecommoncarotidarterytoentertheinternaljugularveinaloneorwiththe
commonfacialvein.
MIDDLETHYROIDVEIN
Themiddlethyroidveinarisesonthelateralsurfaceoftheglandatabouttwothirdsofits
anteroposteriorextent.Noarteryaccompaniesit.Itcrossesthecommoncarotidarteryto
openintotheinternaljugularvein.Thisveinmaybeabsentor,occasionally,double.The
extraveinisinferiortothenormalone;ithasbeencalledthefourththyroidvein.The
importanceofthesemiddlethyroidveinsisintheirvulnerabilityduringthyroidectomy.
INFERIORTHYROIDVEIN
Page91of203
Theinferiorthyroidveinisthelargestandmostvariableofthethyroidveins;theright
andleftsidesareusuallyasymmetric.Therightveinleavesthelowerborderofthe
thyroidgland,passesanteriortothebrachiocephalicartery,andenterstheright
brachiocephalicvein.Theleftveincrossesthetracheatoentertheleftbrachiocephalic
vein.Rarely,therightveincrossesthetracheatoentertheleftbrachiocephalicvein,
sometimesformingacommontrunkwiththeleftvein.Thiscommontrunkiscalledthe
thyroidimavein.
Lymphatics
Severalbroadpatternsoflymphaticdrainageofthethyroidglandhavebeenproposed
(Fig.159).Eachconceptualizationisbasedonthesamefacts;eachiscorrect.Wewill
followthatofHollinshead36(Fig.159C).TheactualdrainageisshowninFig.
160.FIG.159.
Threeconceptsofthelymphaticdrainageofthethyroidgland.A,Edisetal.352B,
McGregorandDuPlessis.76C,Hollinshead.36Allthreeconceptsarecorrectandbased
onthesamefacts.(ModifiedfromTzinasS,DrouliasC,HarlaftisN,
AkinJTJr,GraySW,SkandalakisJE.Vascularpatternsofthethyroidgland.AmSurg
1976;42:639644;withpermission.)

FIG.160.
Page92of203
Thelymphnodesreceivingdrainagefromthethyroidgland.Afterthedescriptionof
Rouviere.359(ModifiedfromTzinasS,DrouliasC,HarlaftisN,AkinJTJr,GraySW,
SkandalakisJE.Vascularpatternsofthethyroidgland.AmSurg1976;42:639644;with
permission.)
PATTERNSOFDRAINAGE
MedianSuperiorDrainage
Threetosixvesselsarisefromthesuperiormarginoftheisthmusandfromthemedial
marginsofthelaterallobes.Thesevesselspassupwardinfrontofthelarynxtoendinthe
digastriclymphnodes.Somevesselsmayenteroneormoreprelaryngeal(Delphian)
nodesjustabovetheisthmus.Secondarydrainagemaybetoupperjugularnodeson
eithersideortopretrachealnodesbelowthethyroidbyavesselpassingfromthe
Delphiannodesdownwardoverthefrontofthethyroid.
Ithasbeensuggestedthatthereisaconnectionbetweenthelymphaticdrainageofthe
superiorthyroidarteryandtheorbitbywayofthejugularchainofcervicallymph
nodes.114Inneithertheorbitnortheeyeitselfcanlymphaticvesselsbe
demonstrated.115Theimmediatecauseofexophthalmusassociatedwiththyroiddisease
istheenlargementoftheextraocularmuscles,especiallytheinferiorrectusandinferior
oblique.Thyroidantigenorantigenantibodycomplexesreachingtheeyefromthe
thyroidglandproduceanautoimmuneresponseintheextraocularmuscles.
MedianInferiorDrainage
Severallymphvesselsdrainthelowerpartoftheisthmusandthelowermedialportions
ofthelaterallobes.Theyfollowthe
Page93of203
inferiorthyroidveinstoendinthepretrachealandbrachiocephalicnodes.Rightand
LeftLateralDrainage
Lymphatictrunksarisefromthelateralborderofeachlobe.Superiorlytheypassupward
withthesuperiorthyroidarteryandvein.Inferiorlytheyfollowtheinferiorthyroid
artery.Betweenthesetwogroups,somevesselspasslaterally,anteriorly,orposteriorlyto
thecarotidsheathtoreachthelymphnodesoftheinternaljugularchain.Occasionally,
suchvesselsdrainintothe
rightsubclavianvein,jugularvein,orthoracicductwithoutpassingthroughalymph
node.116PosteriorDrainage
Posteriorlymphaticvesselsarisefromtheinferomedialsurfacesofthelaterallobesto
drainintonodesalongtherecurrentlaryngealnerve.Occasionally,aposteriorascending
trunkfromtheupperpartofthelobereachestheretropharyngealnodes.
METASTATICSPREAD
Arepresentationoflymphnoderegionsofimportanceformanagementofthyroid
carcinomaisseeninFig.161.Lymphnodegroupsatthehighestriskforregional
metastasisfromdifferentiatedthyroidcarcinomaareshowninFig.162.
FIG.161.

Page94of203
Lymphnoderegionsofimportanceformanagementofthyroidcarcinoma.(Modified
fromCallenderDL,ShermanSI,GagelRF,BurgessMA,GoepfertH.Cancerofthe
thyroid.In:MyersEN,SuenJY(eds).CanceroftheHeadandNeck(3rded).
Philadelphia:WBSaunders,1996,p.485515;withpermission.)
FIG.162.
Diagramillustratinglymphnodegroupsathighestriskforregionalmetastasisfrom
differentiatedthyroidcarcinoma.(ModifiedfromGoepfertH,CallenderDL.
Differentiatedthyroidcancerpapillaryandfollicularcarcinoma.AmJOtolaryngol
1994;15:167179;withpermission.)
AstudybyGemsenjageretal.117ofpatientswithdifferentiatedthyroidcarcinoma
concludedthatpapillarycarcinomapT13N0M0andminimallyinvasivefollicular
carcinomawithoutnodalordistantmetastasiscanbeadequatelytreatedwith
hemithyroidectomyortotalthyroidectomyonlyandwithoutradioiodine,whileallthe
othertumorssuchasinvasivefollicularcancerweretreatedadequatelywithtotalbilateral
lobectomyandradioiodine.
Feind118foundmetastaticinvolvementofmiddlejugularlymphnodesin85of111
specimensfrompatientswiththyroidcarcinoma.In67ofthese,lowerjugularnodeswere
positive.Submandibularandmediastinalnodeswererarelyaffected.
Table15,basedonmorethan1,000patientsofShahaetal.,119summarizesthe
incidenceofnodalmetastasisanddistantmetastasisindifferentiatedthyroidcarcinoma.
Shahaetal.concludedthattheriskofnodalanddistantmetastasisvaries
Page95of203
considerablybasedonindividualhistologicvariety.Table15.IncidenceofMetastasis
inThyroidCarcinoma
Source:DatafromShahaAR,ShahJP,LoreeTR.Patternsofnodalanddistant
metastasisbasedonhistologicvarietiesindifferentiatedcarcinomaofthethyroid.AmJ
Surg172:692694,1996.
NodalMetastasis
DistantMetastasis
Papillary
61%
10%
Follicular
30%
22%
Hurthlecell
21%
33%
EditorialCommentTheassociationoftruefollicularcarcinomasofthethyroidwith
nodalmetastasesisrareinmyexperience

andintheexperienceofmostcurrentdaysurgicalpathologists.ThedataofShahaet
al.119areretrospectiverecorddatathatincludemanypatientsfromanearliererawhen
manypathologistswerenotmakingthedistinctionbetweentruefollicularcarcinomas
andthefollicularvariantofpapillarycarcinomaofthethyroid.Thedistinctionisbased
oncytologicratherthanhistologiccriteria.Whenthisdistinctionismade,nodal
metastasesareverycommoninpapillarycarcinomaofthethyroidandarerarein
follicularcarcinoma(includingtheoxyphilvariant).(RogerS.Foster,Jr.,MD)
Innervation
Thethyroidglandisinnervatedbythesympatheticsystemfromthesuperior,middle,and
inferiorgangliaofthecervicalchain.Butinthyroidsurgerytherecurrentandsuperior
laryngealnervesoftheparasympathetic(vagus)system(whichplaynoroleinthe
innervationofthegland)areofutmostimportance,soweconsiderthemhere.
RecurrentLaryngealNerves(InferiorLaryngeal)
NORMALANATOMY
Therightandleftrecurrentlaryngealnervesareintimatelyrelatedtothethyroidgland.
Therightrecurrentnervebranchesfromthevagusasitcrossesanteriortotheright
subclavianartery.Therightrecurrentnerve(Fig.163B)loopsaroundthesubclavian
arteryfromposteriortoanterior,crossesbehindtherightcommoncarotidandascendsin
ornearthetracheoesophagealgroove.Itpassesposteriortotherightlobeofthethyroid
glandtoenterthelarynxbehindthecricothyroidarticulationandtheinferiorcornuofthe
thyroidcartilage.
FIG.163.
Page96of203
Theembryonicaorticarchesandtherecurrenceofthelaryngealnerve.A,Normal
embryowiththird,fourth,andsixthaorticarchespresent.Thelaryngealnervearisesfrom
thevagusnerveandpassesunderandbehindthesixthaorticarch.B,Normaladult.On
theright,thelaryngealnervepassesunderthesubclavianartery;ontheleft,itpasses
undertheligamentumarteriosum.C,Inthepresenceofaretroesophagealright
subclavianartery,thenervepassestothelarynxwithoutrecurring.D,Inthepresence
ofarightaorticarch,therightnerveloopsunderthearch;theleftnervepassesdirectlyto
thelarynx.CandDareencounteredinlessthan1percentofspecimens.(Modifiedfrom
SkandalakisJE,DrouliasC,HarlaftisN,TzinasS,GraySW,AkinJTJr.Recurrent
laryngealnerves.AmSurg1976;42:629634;withpermission.)
Theleftrecurrentnerveariseswherethevagusnervecrossestheaorticarch,justdistalto
theoriginoftheleftsubclavianarteryfromtheaorticarch.Itloopsundertheligamentum
arteriosumandtheaorta,andascendsinthesamemannerastherightnerve.Bothnerves
crosstheinferiorthyroidarteriesnearthelowerborderofthemiddlethirdofthegland.
VARIATIONS
Severalvariationsmayoccurinthecoursesoftherecurrentnerves.Allservetoincrease
thepossibilityofinjurytothenerveduringthyroidsurgery.
KatzandNemiroff120visualized1,117recurrentlaryngealnerves.Theyreportedthat
747(63%)bifurcatedortrifurcatedmorethan0.5cmfromthecricoidcartilage.Bilateral
nervebifurcationwasobservedin170patients.

Inanearlierversionofthisresearch,theseauthorswiselyconcludedthat"extralaryngeal
branchesoftherecurrentlaryngealnervearenotananatomicrarity.Therefore,thyroid
surgerymustincludeidentificationandpreservationoftherecurrent
Page97of203
laryngealnerveandallofitsdivisions."121
Inabout1percentofpatients,therightrecurrentnervearisesnormallyfromthevagus,
butpassesmediallyalmostdirectlyfromitsorigintothelarynxwithoutloopingunderthe
subclavianartery(Fig.163C).Inthesecases,therightsubclavianarteryarisesfromthe
descendingaortaandpassestotherightbehindtheesophagus.Thisanomalyis
asymptomatic,andthethyroidsurgeonwillrarelybeawareofitpriortooperation.Even
lesscommonisanonrecurrentleftnerveinthepresenceofarightaorticarchanda
retroesophagealleftsubclavianartery(Fig.163D).
Inthelowerthirdofitscourse,therecurrentlaryngealnerveascendsbehindthe
pretrachealfasciaataslightangletothetracheoesophagealgroove.Inthemiddlethirdof
itscourse,thenervemaylieinthegroove,medialtothesuspensoryligamentofthe
thyroidgland(ligamentofBerry),withintheligament,orwithinthesubstanceofthe
thyroidgland.
Skandalakisetal.122examinedthecourseoftherecurrentlaryngealnervein102
cadavers(204sides).Inabouthalfofthespecimens,thenervelayinthe
tracheoesophagealgroove.Intheotherhalf,mostwereanteriortothegroove
(paratracheal);afewlayposterior(paraesophageal).In8ofthe204sides,thenervelay
withinthegland(Fig.164).Otherworkershavefounda
slightlyhigherpercentageofintraglandularnerves.123FIG.164.
Page98of203
Thecourseoftherecurrentlaryngealnerveatthethyroidglandin102cadavers.
Abouthalfthenerveswerefoundinthegroovebetweenthetracheaandtheesophagus.
A,Lateralview.B,Crosssectionalview.(ModifiedfromSkandalakisJE,DrouliasC,
HarlaftisN,TzinasS,GraySW,AkinJTJr.Recurrentlaryngealnerves.AmSurg
1976;42:629634;withpermission.)
EditorialCommentThisdescriptionofa4percentincidenceofintraglandularrecurrent
nerves122issurprisingtome.Intheprocessofdissectingwellover1000thyroidlobes
withatechniquethatroutinelyidentifiedtheinferiorlaryngeal(recurrent)nerve,Idonot
recallatrueintraglandularnerveinabenignlobe.Sometimesthenervewasenfoldedby
thelobulationsofanadenomatousgoiter,butwasalwaysreadilyfreedbydissectingin
theproperplane.Itiscriticalthatthedissectionbecarriedoutintheproperplaneinorder
toeasilyandsafelyrotatethethyroidlobeupoutofthetracheoesophagealgroove.
(RogerS.Foster,Jr.,MD)
Theseniorauthorofthischapter(JES)feelsverystronglythatthe"recurrentlaryngeal
nerve"shouldbenamedorrenamedtheinferiorlaryngealnerve.
WequotefromSchweizerandDorfl124:
[I]tisparticularlyinterestingforlaryngealsurgeonstonoticetheminorvariabilityof
branchingoftheinferiorlaryngealnerveandofitsmodeofentranceintothe

hypopharynx.Eveninthecaseofaunilateralsingletrunk,thenervepassesjustbehind
thecricothyroidjointandcanbeeasilyidentified.Variations...weremainlylimitedtothe
leveloftheextralaryngealdivisionoftheinferiorlaryngealnerve.Thus,thesurgeoncan
relyonpreciseandconsistentlandmarksinthispartofthebody,asinotheranatomical
locations.
Therecurrentlaryngealnerveissafestandleastvisiblewhenitliesinthe
tracheoesophagealgroove.Itismostvulnerablewhenittraversesthethyroid
parenchyma.Whereitrunsinthesuspensoryligamentofthethyroid,itmustbeidentified
andprotectedbeforetheligamentisdivided.
Therecurrentlaryngealnervecrossestheinferiorthyroidarteryatthemiddlethirdofthe
gland.Itmaylieanteriororposteriorto,
orbetweenthebranchesoftheartery.125Lekacosetal.126reportedthatmostrecurrent
laryngealnerves(approximately80%)arelocatedeitherposteriortoorbetweenthe
branchesoftheinferiorthyroidartery.Thethreemajortypesofcrossingswere
shownpreviouslyinFig.157AC.AseriesbySkandalakisetal.122showedthatthe
rightnervemostfrequentlylaybetweenarterialbranches(48percent);theleftnervewas
usuallybehindtheartery(64percent).Table16showstherelativeincidenceofthetypes
ofcrossing.Noonepatterncanbeconsiderednormal;thesurgeonmustbepreparedfor
anyconfigurationofartery
Page99of203
andnerve.
Table16.RelationshipofRecurrentLaryngealNerveandInferiorThyroidArtery
PerCentFrequency
102Cadavers
1246CasesFromLiterature
Relation
Right
Left
BothSides
BothSides
Nerveanteriortoartery
31.4
9.8
20.6
21.1
Nerveposteriortoartery
19.6
63.7
41.6
50.4
Nervebetweenbranchesofartery
48.0
26.5

37.3
24.8
Nonrecurrentnerveandother
1.0

0.5
3.6
100.0
100.0
100.0
100.0
Source:SkandalakisJE,DrouliasC,HarlaftisN,TzinasS,GraySW,AkinJTJr.The
recurrentlaryngealnerve.AmSurg42(9):629634,1976;withpermission.
KreyerandPomaroli127reportedananastomosisbetweentheexternalbranchofthe
superiorlaryngealnerveandtherecurrentlaryngealnerve.
Sturnioloetal.128emphasizedthatthesecrettoavoidinginjurytotherecurrentlaryngeal
nerveduringthyroidsurgeryisasfollows:(1)deepknowledgeofthesurgicalanatomyof
thethyroidregion;(2)totalextracapsularthyroidectomy;(3)athoroughsearch,
identification,andexposureofthenerveitself;and(4)followingthecourseofthenerve
withcare.
AccordingtoProcaccianteandcolleagues,129aftertherecurrentlaryngealnerveismade
tautbyupwardandmedialtractionofthethyroid,itmaybepalpatedcaudallytothe
inferiorpoleofthegland.Thismaneuveraidedsafedissectionintheregionofthe
inferiorthyroidartery.
Marchesietal.130reportedanoccurrencerateof0.34%foranonrecurrentinferior
laryngealnerveontherightside,andextremerarityontheleftside.Theyreportseven
casesofnonrecurrentlaryngealnerve,andemphasizethediagnosticaccuracyofangio
MRfortheanatomicidentificationofthevascularanomalythatinvariablyoccurswith
thenervemalformation.
Thenonrecurrentnerve(leftorright,whenpresent)maypassdirectlytothelarynxwith
norelationtotheinferiorthyroidartery(Fig.157D),orsuchanervemaylooparound
theartery(Fig.157E).
Avisseetal.131reported17casesofarightnonrecurrentinferiorlaryngealnerve.Intwo
ofthesecasesanaberrantrightsubclavianarterycoexistedwithanonrecurrentinferior
laryngealnerve.
Sandersetal.,132whofoundsevencasesofnonrecurrentlaryngealnervesin1,000
thyroidectomies,reportedthefollowing:
Intwoofthesesevencases,bothanonrecurrentnerveandanadditionalrecurrentbranch
werepresentontherightside.Thisdoublenervepresentationhasnotbeendescribed
before.Unlessoneisawareofthispossibility,onemightinadvertentlyinjurethemajor
nonrecurrenttrunk,havingidentifiedonlyasmallrecurrentbranch.Weemphasizethe
needforacompletenerve
Page100of203

identificationtechnique.
Miyauchietal.133reportedgoodresultswithsimpleneurorrhaphyorwithgraft(vagus
nerveansacervicalis)oftheinjured
recurrentnerve.Their8patientsrecoveredfromhoarseness,andmaximumphonation
improved.Steinbergetal.134statedthatbranchesoftherecurrentlaryngealnerve(motor
aswellassensory),togetherwithsympatheticnerves,supplythelarynxbeneaththe
cords,pharynx,cervicalesophagus,andcervicaltrachea.
EXPOSURE
Exposureoftherecurrentnerveduringanyprocedureonthethyroidisasoundsurgical
principleandshouldbedonewhereverpossible.Ifthenervecannotbefoundreadily,the
surgeonmustavoidtheareasinwhichitmaybehidden.Fibrosis,increasedbleeding,and
lackofclearanatomicrelationshipsareresponsibleformostnerveinjuries.Postoperative
explorationfor
hemorrhagealsoisassociatedwithahigherriskofnerveinjury.135
Atonetimetherecurrentnervewasconsideredsodelicatethatifarecurrentlaryngeal
nerveisseenduringthyroidectomy,itis
injured.136Attheotherextremearethosewhowouldrequiredemonstrationofthe
nervebydirectstimulationduring
laryngoscopicobservationofthevocalcords.137Webelievethatvisualidentification,
withavoidanceoftraction,compression,orstrippingtheconnectivetissueisallthatis
necessary.Completeanatomicdissectionisnotrequired,butsimpleexposurewill
notdestroyit.Fromtheirinvestigationof803goiteroperationsandaliteraturesearch,
Jatzkoetal.138notedasignificantlyhigherrateofinjurytotherecurrentlaryngealnerve
whenitwasnotidentified(5.2%)thanwhenitwasexposed(1.2%).
Therecurrentlaryngealnerveformsthemedialborderofatriangleboundedsuperiorly
bytheinferiorthyroidarteryandlaterallybythecommoncarotidartery.Thenervecan
beidentifiedwhereitentersthelarynxjustposteriortotheinferiorcornuofthe
thyroidcartilage.139Ifthenerveisnotfound,anonrecurrentnerveshouldbesuspected,
especiallyontheright.
Pelizzoetal.140advisedthatthebestwaytolocatetherecurrentlaryngealnerveduring
thyroidectomyistheZuckerkandlstuberculum,whichislocatedonthelateralportionof
eachofthethyroidlobes,andaccordingtotheseauthorsistheconstantanatomic
landmarkwhenpresent(Fig.165)
FIG.165.
Zuckerkandlstuberculumsize.0,unrecognizable;1,onlyathickeningofthelateraledge
ofthethyroidlobe;2,smallerthan1
Page101of203
cm;3,largerthan1cm.(ModifiedfromPelizzoMR,ToniatoA,GemoG.
Zuckerkandlstuberculum:anarrowpointingtotherecurrentlaryngealnerve(constant
anatomicallandmark).JAmCollSurg1998;187:333336,1998;withpermission.)
ThetubercleofZuckerkandlisthemostposteriorextensionofthelaterallobesofthe
thyroidglandattheleveloftheligamentofBerry141,142(Fig.166).
FIG.166.

TheregionofthetubercleofZuckerkandl(themostposteriorextentofthethyroidlobe)
andthedistalcourseoftherecurrentlaryngealnerve(RLN).TherelationoftheRLNto
theremainingremnantofthyroidandmechanismforpossibleRLNinjuryareshown.
(ModifiedfromThompsonNW.Thyroidgland.In:GreenfieldLJ(ed).Surgery:
ScientificPrinciplesandPractice(2nded).Philadelphia:LippincottRaven,1997,pp.
12831308;withpermission.)
Page102of203
Todigressforamoment,I(JES),theseniorauthorofthischapter,wouldliketopoint
outthatneverinmy50yearsintheanatomylabandoperatingroomdidInoticethe
tubercleofZuckerkandl.Tomyembarrassmentandfrustration,Ihadnotheard
ofthisspecificprotuberanceofthethyroidlobeuntilIreadthepreviouslymentioned
excellentpublicationbyPelizzoetal.140Inthelowerportionofthecourseofthe
recurrentlaryngealnerve,thenervecanbepalpatedasatightstrandoverthetracheal
surface.Thereismoreconnectivetissuebetweenthenerveandthetracheaontheright
thanontheleft.
SuperiorLaryngealNerve
Thesuperiorlaryngealnervearisesfromthevagusnervejustinferiortoitslowersensory
ganglionjustoutsidethejugularforamenoftheskull.Thenervepassesinferiorly,medial
tothecarotidartery.Atthelevelofthesuperiorcornuofthehyoidboneitdividesintoa
large,sensory,internallaryngealbranchandasmaller,motor,externallaryngealbranch,
servingthecricothyroid
muscle143andthecricopharyngeus.Thepointofdivisionisusuallywithinthe
bifurcationofthecommoncarotidartery(Fig.167).
FIG.167.
Page103of203
Branchingofthesuperiorlaryngealnerveandthecarotidarteries.A,Theinternal
branchcrossestheexternalcarotidarteryabovetheoriginofthelingualartery.B,The
internalbranchcrossesbelowtheoriginofthelingualartery.C,Thenervedividesmedial
totheexternalcarotidartery.(ModifiedfromDrouliasC,TzinasS,HarlaftisN,AkinJT
Jr,GraySW,SkandalakisJE.Thesuperiorlaryngealnerve.AmSurg1976;42:635638;
withpermission.)
SunandDong144dissected60adultcadavers(120superiorlaryngealnerves)and
reportedthemorphologyandtopographyofthesuperiorlaryngealnerve,itsbranches,its
anastomoseswiththecervicalsympathetic,anditsrelationstothethyroidgland.An
anastomoticloopconnectingthecervicalsympatheticchainandthedistallaryngealnerve
waspresentin111ofthe120cases.Themorphologyofthisloopmadeitpossibleto
definefivedifferenttypes.Figures168and169arefromtheirinterestingpaper,andwe
urgeallsurgeonswhoperformthyroidsurgerytoreadit.
FIG.168.
Page104of203
Page105of203

Thesketchofthecoronalsectionofthelarynxshowsthesuperiorlaryngealnerve
trunk(s)intheenvironmentofthesternothyroidlaryngealtriangle,whichisbounded
laterallybythesternothyroidmuscle,mediallybytheinferiorpharyngealconstrictorand
cricothyroidmuscles,andinferiorlybythesuperiorpoleofthethyroidgland.a,single
nervetrunk,89sides(74.2%);b,singlenervetrunk,1side(0.8%);c,doublenerve
trunks,24sides(20%);d,doublenervetrunks,4sides(3.3%);e,triplenervetrunks,1
side(0.8%);f,quadruplenervetrunks,1side(0.8%).(ModifiedfromSunSQ,DongJP.
Anappliedanatomicalstudyofthesuperiorlaryngealnerveloop.SurgRadiolAnat
1997;19:169173;withpermission.)
FIG.169.
Variationsoflaryngealnerves.TypeI,Vshapedin94sides(78.33.8%).TypeII,U
shapedin8sides(6.72.3%).TypeIII,Mixedin14sides(11.72.9%).TypeIV,
Juxtaposeddoublein1side(0.80.8%).TypeV,Juxtaposedtriplein1side(0.8
0.8%).SLN,superiorlaryngealnerve;ILN,internallaryngealnerve;SCG,superior
cervicalganglion;CT,communicatingtwig;ELN,externalbranchoflaryngealnerve;
CTB,cricothyroidmusclebranch;GB,thyroidbranch.(ModifiedfromSunSQ,DongJP.
Anappliedanatomicalstudyofthesuperiorlaryngealnerveloop.SurgRadiolAnat
1997;19:169173;withpermission.)
Topreventiatrogenicinjuryofthesuperiorlaryngealnerveduringsurgicaldissection
nearthethyroidapexintheneck,el
GuindyandAbdelAziz145recommendedanatomicallocalizationofthenerveinthe
viscerovertebralangle,functionalidentification,andpostoperativeanalysis.
INTERNALLARYNGEALNERVE
Theinternallaryngealbranchpiercesthethyrohyoidmembranewiththesuperior
laryngealbranchofthesuperiorthyroidarterytoenterandsupplythelarynx.The
internalbranchisrarelyidentifiedbythesurgeon;identificationoccursonlyinthose
caseswhereagreatlyenlargedupperpoleofthethyroidglandrisesabovethesuperior
borderofthethyroidcartilage(Fig.170).Theinternallaryngealnerveprovidesgeneral
sensoryfiberstothelarynxandtheareaofthepiriformrecessofthelaryngopharynx.It
alsoprovidesparasympatheticfibersfortheglandularelementsandsometastefibersthat
supplytastebudsaroundtheepiglottis.
FIG.170.
Page106of203
Relationshipbetweenthe(A)internaland(B)externalbranchesofthesuperior
laryngealnervewiththesuperiorthyroidarteryandtheupperpoleofthethyroidgland.
(ModifiedfromDrouliasC,TzinasS,HarlaftisN,AkinJTJr,GraySW,SkandalakisJE.
Thesuperiorlaryngealnerve.AmSurg1976;42:635638;withpermission.)
EXTERNALLARYNGEALNERVE
Theexternallaryngealbranch,togetherwiththesuperiorthyroidveinandartery,passes
underthesternothyroidmuscles,posteriorandmedialtothevessels.Thenervethen
passesbeneaththelowerborderofthethyrohyoidmuscletocontinueinferiorlyto

innervatethecricothyroidmuscle.Inadditiontoitscontributiontophonation,the
cricothyroidmuscleplaysamajor
roleintheoverallregulationofbreathingbyitscontrolofexpiratoryresistanceand
flow.146
AninvestigationbyWuetal.147suggestedthatinsomeindividualsabranchofthe
externallaryngealnervemayalsocontributetotheinnervationofthethyroarytenoid
muscleandtothesensorysupplyofthevocalfoldofthelarynx.Theypostulatedthatthe
communicatingbranchofthisnervemightrepresentthenerveofthe5thembryonic
branchialarch.
Cerneaetal.148statedthatinjurytotheexternalbranchofthesuperiorlaryngealnerve
willmostlikelyendure,causingapermanentvoicechangeforprofessionalvocalists.
Fatigue,also,iscommonafterinjurytotheexternalbranchofthesuperiorlaryngeal
nerve.Cerneaetal.advisednerveidentificationintheoperatingroom,especiallyfor
patientswithlargegoiters.Thetopographicanatomyandrelationsofthenervesand
thyroidvesselsarepresentedinFigure171.Cerneaandcolleagueshave
alsopresentedfurtherfindingsaboutthesurgicalanatomyofthesuperiorlaryngeal
nerve.149,150FIG.171.
Page107of203
Classificationoftheexternalbranchofthesuperiorlaryngealnerve,accordingtothe
potentialriskofiatrogeniclesionduringahypotheticalthyroidectomy.Type1,Thenerve
crossesthesuperiorthyroidvessels1ormorecentimetersaboveahorizontalplane
passingtheupperborderofthesuperiorthyroidpole.Type2a,Nervecrossingthevessels
lessthan1cmabovetheplane.Type2b,Nervecrossingthevesselbelowtheplane.
(ModifiedfromCerneaCR,NishioS,HojaijFC.Identificationoftheexternalbranchof
thesuperiorlaryngealnerve(EBSLN)inlargegoiters.AmJOtolaryngol1995;16:307;
withpermission.)
Inmostpatients,thebloodvesselsliewithinthevisceralcompartmentoftheneck
beneaththepretrachealfascia,whiletheexternallaryngealnerveliesbetweenthefascia
andtheinferiorpharyngealconstrictormuscle.Thereisthusaplaneofdissection
betweenthevesselsandthenerve.Inabout25percentofindividuals,thenervelies
beneaththefasciatogetherwith
thevessels.151
Histology
Thethyroidglandissurroundedbythethyroidcapsule,whichisathinlayerof
connectivetissue.Fromthecapsule,severalseptaextendwithinthethyroidparenchyma,
whichissubdividedintoseverallobules.Epithelialcells(cuboidalorsquamous)formthe
thyroidfollicles;theyareseparatedbythinconnectivestromawhichisrichinboth
lymphaticandbloodvessels.Smallbundlesofnervesarepresent.
Thereisacolloidalgelatinouscollectioninthecenterofthefollicle.Eachfolliclehastwo
typesofcells:follicularandparafollicular,orCcells.
AccordingtoRossandReith,152thefollicularcellsareresponsibleforthefollowing
actions:synthesisofthyroglobulin,iodination,storageofthyroglobulin,resorptionof

thyroglobulin,hydrolysisofthyroglobulin,andreleaseofthyroidhormoneintotheblood
andlymphatics.
Theparafollicular,orCcells,canbefoundintheconnectivestromabetweenthefollicles
orinthefollicularepithelium.Characteristically,theycontainseveralsecretorygranules.
Page108of203
Physiology
Thefollicularcellsofthethyroidglandproducethethyroidhormonesthyroxine(T4)and
triiodothyronine(T3).Thefollicularcellstrapandconcentrateiodidefromthatserum.
Thefinalproduct,thyroglobulin,accumulateswithinthecolloid.
Figures172and173illustratethesynthesisofthehormonesofthethyroidglandand
theirregulatedsecretion.Anotherfunctionofthethyroidglandisthesecretionof
thyrocalcitonin,whichistheproductoftheparafollicularorCcells.
FIG.172.
Thesynthesisandsecretionofthyroxine(T4)andtriiodothyronine(T3).TSH,thyroid
stimulatinghormone;MIT,
monoiodotyrosine;DIT,diiodotyrosine.(FromPolkHCJr,GardnerB,StoneHH.Basic
Surgery(5thed).St.Louis:QualityMedical,1995;withpermission.)
FIG.173.
Page109of203
Thephysiologicregulationofthyroidhormonesecretionandthethyroidtestswhich
measuretheseparameters.TRH,thyrotropinreleasinghormone;TSH,thyroid
stimulatinghormone;TSI,thyroidstimulatingimmunoglobulins;LATS,longacting
thyroidstimulator;TBG,thyroxinebindingglobulin;FTI,freethyroxineindex.
(ModifiedfromPolkHCJr,GardnerB,StoneHH.BasicSurgery(5thed).St.Louis:
QualityMedical,1995;withpermission.)
ThyroidSurgery
Thesurgicalproceduresforthyroidpathologyaretotalbilaterallobectomy,total
unilateralwithpartialcontralaterallobectomy,andpartialorsubtotallobectomy
(unilateralorbilateral).Thereismuchcontroversyastowhichisthemostappropriate
choiceforeachpatientandeachdisease.Thesurgicalprofessionagreestodisagreeabout
alltheseprocedures.
Recently,minimallyinvasivethyroidsurgeryhasbeenperformedsuccessfully.Ferzliet
al.153reportedfeasibleandsafeminithyroidectomyonglandsnolargerthan7cm.
WeagreewiththeadviceofBlissandcolleagues,154"Minimallyinvasivethyroidectomy
utilizingendoscopictechniquesmayalsoaffectthepracticeofthyroidsurgery.Evenso,
understandingthesurgicalanatomyofthethyroidglandanditspossiblevariationsis
paramounttosafeandeffectivesurgery."
WepresentthevaluableflowchartofJohns155formanagementofsolitarythyroid
nodules(Fig.174).Delbridgeetal.156reportedthattheprocedureofchoiceforbilateral
benignmultinodulargoiteristotalthyroidectomy,sincethatprocedure
Page110of203

obviatesrecurrentgoiterandaneedforsecondarythyroidectomy.
FIG.174.
Managementflowchartforpatientwithsolitarythyroidnodule.TSH,thyroidstimulating
hormone;FNA,fineneedleaspiration;RAD,radiationabsorbeddose.(Modifiedfrom
JohnsME.Thesolitarythyroidnodule.CurrTherOtolaryngol1987;3:226229;
Page111of203
withpermission.)
EditorialCommentIamingeneralagreementwiththemanagementflowcharttaken
fromJohns,155butIwouldsuggestmodificationofthefollowingboxes:
InthesecondboxafterhistoryandphysicalexaminationIwouldrecommendthata
sensitiveTSHtestbedoneastheonlyscreeningtestforthyroidfunction.Themodern
TSHtestinagoodlaboratoryiseffectiveindistinguishinghyperthyroidism(lowTSH
willoccurevenbeforeelevationofT4orT3),hypothyroidism(anelevatedTSHwill
occurbeforelowvaluesforT4andT3),
andeuthyroidism.
Intheboxforfollicularpatternthetermshouldbefollicularneoplasticpattern.Normal
thyroidcellsareofcoursefollicular.
Betweentheboxforautonomousnoduleandtheboxthatindicatessurgeryor131I
therapythereneedstobeinformationonthesizeoftheautonomousnoduleandwhether
theautonomousnoduleiscausinghyperthyroidism.Autonomousnoduleslessthan3cm
indiameterrarely(perhapsnever)causehyperthyroidism.Thenaturalhistoryof
autonomousnodulesisforapproximatelyonethirdtoremainstable,onethirdto
spontaneouslyregress,andonethirdtoprogress.Theonlyindicationsfortreatmentof
autonomoushyperfunctioningnodulesarethattheyarecausinghyperthyroidism,areso
largeastobeacosmeticissue,oraresymptomaticbecauseoftheirsize.
FollowingpatientswithprobablebenignsolitarynodulesafterplacingthepatientsonT4
therapyisapracticeIcarriedoutfor
manyyears,andfrequentlytheobserverhastheimpressionthatthereisregressionofthe
nodule.However,carefulsequentialultrasoundstudieshavefailedtodocumenttrue
regressionofthenodulesatahigherratethanoccursspontaneouslyovertimewithout
T4.IsuspectthatwithT4therapythereisshrinkageofthenormalportionsofthethyroid
glandallowingtheglandto
recedeintotheneckandforthesolitarynoduletobecomelessreadilypalpable.(RogerS.
Foster,Jr.,MD)
Anothersurgicaldilemmaisthetreatmentofhyperparathyroidism,whichisconsideredin
thefollowingsectionontheparathyroidgland.
AccordingtoCooper,157treatmentofhyperthyroidismisstillsomewhatcontroversial.
Americanendocrinologistsadviseantithyroiddrugsforyoungindividuals,butiodine131
foradults.EuropeanandJapaneseendocrinologistsaremorelikelytorecommend
antithyroiddrugsregardlessofthepatientsage.Allovertheworld,surgeryisused
infrequently.
Ronetal.158reportedthatiodine131appearstobesafetreatmentforhyperthyroidism
withoutsignificantlyincreasingtheriskoftotalcancermortality.

Inastudyof124casesofmalignanttumorsofthethyroid,Skandalakisetal.159found
papillarycarcinomatobethelargestgroup,accountingfor39.5%Theyreportedthatthis
typeoftumoristheleastmalignant.
Inpapillarycarcinomaofthethyroid,Noguchietal.160statedthatmicroscopic
involvementofthecervicallymphnodesis80%.
Mirallieetal.161presentedtablesshowinglocalizationoflesioninpapillarythyroid
carcinoma(Tables17,18).Clark,162inhisinvitedcommentary,madethefollowing
recommendations:(1)Thesurgeonshouldlookfornodesinthecentralneck;ifpresent,
theyshouldberemoved;(2)Therapeuticfunctionalmodifiedradicalneckdissection
shouldbeperformed,withpreservationofmotornervesintoto;(3)Prophylacticneck
dissectionshouldnotbeperformed,sinceproportionallyfewpatientstreatedwith
irradiationdevelopnodalrecurrenceofmetastases;(4)Berrypickingisuseless,since
withpalpablemetastaticlymphnodes,smallernodesalsohavemicrometastases.
Table17.LocalizationofNodeInvolvement
No.inNodePositivePatients
NodeLocalization
Ipsilateral(n=71)
Contralateral(n=30)
Page112of203
Paratracheal
60(83.3%)
25(34.7%)
Midjugular
44(61.1%)
12(16.7%)
Supraclavicular
26(36.1%)
5(6.9%)
Subdigastric
20(27.8%)
2(2.8%)
Source:MirallieE,VissetJ,SaganC,HamyA,LeBodicMF,PaineauJ.Localization
ofcervicalnodemetastasisofpapillarythyroidcarcinoma.WorldJSurg1999;23:970
974;withpermission.
No.bySiteinThyroidLobe
Node
UpperThird
MiddleThird
LowerThird
Diffuse
Unknown
Isthmic
Ipsiparatracheal

9
6
10
18
14
3
Ipsijugular
6
5
6
15
11
1
Ipsisupraclav
3
3
2
13
5
0
Ipsisubdig
7
1
1
5
5
1
Contralatparatrach
2
4
1
10
8
0
Contralatjugular
1
2
0
7
2
0
Contralatsupraclav
0
2

1
2
0
0
Contralatsubdig
0
0
0
1
1
0
Table18.NodeInvolvementAccordingtoLocalizationoftheTumorintheThyroid
Lobe
Ipsiparatracheal:ipsilateralparatrachealnodes;Ipsijugular:ipsilateraljugularnodes;
Ipsisupraclav:ipsilateralsupraclavicularnodes;Ipsisubdig:ispilateralsubdigastric
nodes;Contralatparatrach:contralateralparatrachealnodes;Contralatjugular:
contralateraljugularnodes;Contralatsupraclav:contralateralsupraclavicularnodes;
Contralatsubdig:contralateralsubdigastricnodes.
Source:MirallieE,VissetJ,SaganC,HamyA,LeBodicMF,PaineauJ.Localization
Page113of203
EditorialCommentIamingeneralagreementwithmostoftherecommendationsof
Clark162andIsuspectthatourapproachtoresectionofclinicallyidentifiablenodal
metastasesofpapillarycarcinomaofthethyroidissimilar.Thetermberrypicking
meansdifferentthingstodifferentsurgeons.Particularlyalongtherecurrentnerves,
nodesmustbepickedinawaythatsparesthenerve.Thenodesarenotremovedas
individualnodesbutarepickedorstrippedasacluster.Strippingorpickingthe
metastaticnodesisaidedsomewhatbythetendencyofpapillarycarcinomametastasesto
elicitaslightfibroticreactionthathelpsthenodesclingtoeachother.Frequentlythe
nodesareverysmallandmightbeoverlookedbyasurgeonunfamiliarwiththeir
appearanceandfeel.Also,itmaybenecessarytocontinuethestrippingorpicking
downintothemediastinumifthereisclinicalevidenceoffurthernodalmetastases.I
agreethatprophylacticneckdissectionshouldnotbeperformed.Inmyexperienceafter
carefulintraoperativeinspectionfornodalmetastasesandremovalofclinicallyevident
nodes,nodalrecurrenceofpapillarycarcinomaofthethyroidisveryuncommon,even
withoutradiotherapy.(RogerS.Foster,Jr.,MD)
Chenetal.163reportedthatalthoughrare,isolatedmetastaticdiseasetothethyroidgland
fromnonthyroidprimarytumorshavebeenobserved,includingthefollowing:
Boydetal.164recommendpreoperativefineneedleaspirationofthyroidtumorasa
powerfuldiagnostictoolforthyroidcancer.Tarantinoetal.165statedthattheroleof
fineneedleaspirationbiopsyaswellasflowcytometryfortheevaluationofneck
adenopathyhasnotbeendefined,butaspirationisreliablefordiagnosisofmetastatic
disease.

Matsuzukaetal.166reportedthattherarethyroidlymphomamaybedetectedbythe
Southernblot(IgHJHorIgLJIprobes)inapproximately85%ofthecases.
Smithetal.167describedprimaryHodgkinsdiseaseofthethyroidglandandtheyfound
19similarcasesintheliterature.Hermannetal.168advisedreoperationinrecurrent
hyperthyroidism,intheabsenceofcontraindications,sincethisprocedureis
safeandeffective.
EditorialCommentThereportofHermannetal.168isbasedonasurgicalexperience
withnineteenpatients.Secondarysurgicalprocedures,withthetissueplanesand
anatomydistortedbyprevioussurgery,havehadhighercomplicationratesthanprimary
thyroidsurgeryinthehandsofmanysurgeonsinthepast.Itisforthisreasonthatthe
secondaryablativeprocedureofchoiceisusuallyconsideredtoberadioiodine.(RogerS.
Foster,Jr.,MD)
ofcervicalnodemetastasisofpapillarythyroidcarcinoma.WorldJSurg1999;23:970
974;withpermission.
Renalcellcarcinoma
5cases
Esophagealadenocarcinoma
1case
Pulmonarysquamouscellcarcinoma
1case
Gastricleiomyosarcoma
1case
Lingualsquamouscellcarcinoma
1case
Parotidglandcarcinoma
1case
Page114of203
Loetal.169reportedthefollowing:Patientswithanaplasticcarcinomaofthyroid
haveadismalprognosisheraldingimminentdeath.Surgicalablationfollowedby
adjuvanttherapycanprovidepalliationforselectedpatientsonly.Theseniorauthorof
thischapter(JES)hadonlyonesuchcaseanddespitethefactthathecauterizedand
removedprotrudinganaplasticthyroidtissuedailyandperformedatracheostomy,and
despiteirradiation,thepatientdiedafewmonthsaftersurgery.
Dharetal.170reportedthattumormicrovasculardensitiesperhapsisanewprognostic
indicatorfordifferentiatedthyroidcarcinoma.Dharetal.indicatedthatpatientswith
thyroidcarcinomawhohavedThdPaseexpressionandhightumorvascularityprobably
willneedadjuvantradiotherapy.
SandersandSilverman171statedthatfollicularandHurthlecellcarcinomaofthethyroid
glandwithminimalcapsularinvasionbehaveinabenignway,andboththesetypeshave
asimilarprognosis.
Gaugeretal.172statedasfollows:[T]hesizeofafollicularlesioncannotbeusedto
predictafinaldiagnosisoffollicularcarcinomaandisofnovaluewhenmaking
intraoperativedecisionsabouttheextentofthyroidresection.

Invasionofthecervicovisceralaxis(larynx,trachea,andesophagus)bythyroid
carcinomaisarareoccurrence.Accordingto
Machensetal.,173neoplasticspreadinthisareaismoreoftencausedbyextrathyroidal
growththanbynodalmetastasis.Theyrecommendparatrachealandparaesophageal
lymphnodeclearanceatprimaryoperation.
Inastudyofpatientswhohadundergoneprimaryandreoperativesurgeryforsporadic
medullarythyroidcarcinoma,Gimmetal.174advisedtranssternalmediastinallymph
nodedissectionforthosewithlymphnodemetastases.
Hayetal.175statedthatbilateralthyroidlobectomy(BTL)forthyroidpapillary
carcinomaisthepreferredinitialsurgicalprocedureoverunilaterallobectomy(UL)since
theratesforlocalrecurrenceandnodalmetastasiswithULare14%and19%,
respectively,comparedto2%and6%withBTL.
Hereditarymedullarythyroidcarcinomashouldbetreatedwithprophylactictotal
thyroidectomyduringchildhood;ifcalcitoninlevelsareelevatedorifchildrenareolder
than10years,lymphadenectomyshouldbeincludedaccordingtoDralleetal.176
WequotefromKebebewetal.177onreoperationofresidualmedullarythyroid
carcinoma(MTC):
AlthoughreoperationinpatientswithresidualMTCrarelyresultsinbiochemicalcure,
cervicalreexplorationissafeandinselectedpatientsmaylimitMTCprogression.Lateral
cervicalnodedissectioncouldbebeneficialatthetimeofinitialsurgicaltreatment
becauseofthehighfrequencyofresidualMTCinthelateralcervicalnodes.Noninvasive
imagingstudieswerehelpfulbutfarfromperfectforguidingthereexplorationfor
locoregionalresidualMTC.
Discussionofthispaperincludedcommentsonlateralaberrantthyroidtissue,benign
metastasizinggoiter,andlateralanlages;monitoringofserumcalcitoninandCEAlevels;
andtheimportanceofearlyoperationforcure.Weurgetheinterestedreadertostudythis
articleinitsentirety.
WhileVoutilainenetal.178statedthatthereiscurrentlynocurativetherapyforpatients
withanaplasticthyroidcarcinoma,
Nilssonetal.179suggestedthatacombinationofpreoperativehyperfractionated
acceleratedradiotherapy,doxorubicinpreandpostoperatively,anddebulkingsurgery
(whenpossible)mayproducebetterlocalcontroland,possibly,alsoincreasedsurvival
rate.
Forthemanagementofamiodaroneassociatedthyrotoxicosis,astudybyHamoiret
al.180suggestedthatthyroidectomyismoreeffectivethanconventionalmedical
treatment.
Chaoetal.181reportedthatmostofthepatientswiththyroidcarcinomaandconcurrent
hyperthyroidismhavesmallcarcinomas.
Page115of203
Shimizuetal.182reportedendoscopicresectionofthyroidtumorsin5patients.
Forwelldifferentiatedthyroidcarcinomasinvadingthetrachea,Yangetal.183
recommendsurgicalresectionfollowedby
primaryreconstruction.

AnatomicComplicationsofThyroidectomy
VascularInjury
Thyroidarteriesmustbeligatedcarefully;thesuperiorthyroidarterytendstoretract,thus
fillingthefieldwithblood.
Thesuperiorthyroidarteryshouldnotbeclampedabovetheupperpoleofthethyroid
becausetheexternallaryngealnervemaybeinjured.Ifthearteryisclampedatthepole,a
branchmayescape,withresultinghemorrhage.Thesuperiorpole,togetherwiththe
artery,shouldbeclampedandligated(Fig.175).
FIG.175.
Thesuperiorthyroidvesselsshouldbeclampedanddividedwithinthesubstanceofthe
upperpoleofthethyroidgland.Failuretosecurethesevesselsadequatelywillresultin
massivehemorrhage.(ModifiedfromAkinJTJr,SkandalakisJE.Techniqueoftotal
thyroidlobectomy.AmSurg1976;42:648656;withpermission.)
EditorialCommentThiswholediscussionofusingclampsaroundthesuperiorpoleofthe
thyroidbothersme.Ihavealwayspreferredanincontinuitytechniqueofligationofthe
superiorpolevessels(ortheirbranches)usingfineligatures.Suchatechniquepermits
visualizationoftheexternallaryngealnerve,andpushingitoutofharmswayif
necessary.Amorecompleteremovaloftheglandisaccomplished,andthereisless
chanceofaclampslipping,ortearingthearteryfromexcesstraction.(RogerS.Foster,
Jr.,MD)
Separationoftheinferiorthyroidarteryfromtherecurrentlaryngealnerverequirescare.
Wherethenervepassesbetweenbranchesoftheartery,theindividualbranchesmustbe
ligatedanddividedseparately.Retractionofthearterycanresultinahastyattemptat
hemostasisthatwillinjuretherecurrentnerve.
Avisseetal.131reviewed17casesofrightnonrecurrentinferiorlaryngealnerve.An
aberrantrightsubclavianarterywaspresent
Page116of203
in2cases.Fromtheircasesandfromareviewoftheliteraturetheauthorsconclude
thatthisarterialanomalyisalwayspresentwithrightnonrecurrentinferiorlaryngeal
nerve.Theauthorsreviewtheanatomicandembryologicbasesanddiscussthediagnostic
andtherapeuticimplicationsofthisdoubleanomaly.
Themiddlethyroidveinisshortandeasilytorn.Ifitisdividedaccidentally,itwill
retract,makinghemostasisdifficult.Withtoomuchtractionofthethyroidgland,thevein
becomesflattenedandbloodless,makingitunrecognizableuntilitissevered.Thetearis
oftenatthejunctionofthemiddlethyroidveinandjugularvein,presentingthedangerof
anairembolism.Suchaninjurytotheveinrequiresimmediaterepair.
Bleedingduringthyroglossalductcystsurgery,pyramidallobeexcision,ordivisionofa
thickthyroidisthmusduringthyroidsurgeryortracheostomyismostlikelyduetoinjury
ofthecricothyroidartery.Thisarteryspringsfromthesuperiorthyroidarteryorfromits
anteriorbranch.Itfollowstheupperborderofthecricothyroidmuscleandmembrane
(Fig.176).
FIG.176.
Nervesandarteriesofthelarynx,lateralview.

Thethoracicductisrarelyinjuredinthyroidectomy,althoughinjuryduringradicalneck
dissectionisnotunknown.Theductcanbeligatedwithimpunity.
Page117of203
OrganInjury
Thepleuraisrarelyinjured,butwehaverecordsoftwopatientsinwhompneumothorax
occurred.Inone,ahugetoxicgoiterextendedfarlaterally;intheother,thethyroidwas
retrosternal.
Bothanteriorlyandposteriorlythetwopleuraeapproachthemidline,andhenceeach
other.Intrathoracicgoitercandescendintotheanteriororposteriormediastinum,
bringingthethyroidglandclosetothepleura(Fig.177).
FIG.177.
Anenlarged,retrosternalthyroidglandshowingitsrelationtothepleura(dottedline).
(ModifiedfromHarlaftisN,TzinasS,DrouliasC,AkinJTJr,GraySW,SkandalakisJE.
Rarecomplicationsofthyroidsurgery.AmSurg1976;42:645647;withpermission.)
PandyaandSanders184describedamethodwherebyaFoleycatheterwasplacedbeyond
thesubsternalcomponentofthegoiter.Thecatheteranditsinflatedballoonwere
carefullytractionedupward,deliveringthesubsternalgoiterintheneck.Thisprocedure
wasusedsafelyandsuccessfullyontwopatients,therebypreventingtheneedfora
sternotomy.Thoughthereporteduseofthisprocedureisverylimited,perhapsthe
procedureissound.
Thetracheaandesophaguscanbeinjuredinthepresenceofthyroiditis,calcified
adenoma,ormalignancy.Thetruecapsuleofthethyroid,thepretrachealfascia,the
trachea,andtheesophaguscanbesofixedtooneanotherthatvigorousattemptsat
separationmayperforatethetrachea.Atrachealperforationmayrequireimmediate
tracheostomy.
Theparathyroidglandsareclosetotheposteriorthyroidcapsule.Withtotalconservative
thyroidectomy,hypocalcemiaoccurs
in20to25percentofpatients.185,186Inmostofthesethedropincalcium(perhaps
owingtotraumatotheglands)issmallandtransitory;itpersistsin14percentofcases.
Inradicalthyroidectomy,theincidenceishigher.Preservationofonlyoneparathyroid
glandwillavoidthesymptomsofhypoparathyroidism.
EditorialCommentChronichypoparathyroidismisaverydifficultdiseaseforthepatient.
Ithinkthatthe1to4percentratesofpermanenthypoparathyroidsmarerelativelyhigh
butwillprobablybelowerinthehandsofonlythemostexperiencedand
Page118of203
skilledsurgeons.ItisforthisreasonthatIrecommendaconservativeapproachin
selectingthepatientsfortotalthyroidectomy(about20percentofthepatientswith
thyroidmalignancy).(RogerS.Foster,Jr.,MD)
NerveInjuryVagusNerve
FernandoandLord187presenteddatatoindicatethatinadvertentinterruptionofthe
vascularsupplyofthevagusnervecouldbethehithertounsuspectedcauseofseveral
neurologicproblemsfollowingthyroidectomy,carotidendarterectomy,andsurgeryfor

correctionofaorticarchaneurysms.Itispossiblethatsomepostoperativeneurologic
problemsattributedtoaccidentalinjuryoftherecurrentlaryngealnervemighthave
actuallyresultedfromischemiaoredemaofthevagusnerve,withsimilarresults(Figs.1
78,179,180,and181).
FIG.178.
Dissectionoftherightsideofthehumanneck.Thelargevagalartery(A)receives
reinforcingbranches(R)fromthecommon(B)andinternal(I)carotidarteries.
Inadvertentdamagetothesevesselsincarotidendarterectomymayaccountforinjuryto
thevagusnerve(N)andsubsequentvagalpalsy.(ModifiedfromFernandoDA,Lord
RSA.Thebloodsupplyofthevagusnerveinthehuman:itsimplicationincarotid
endarterectomy,thyroidectomyandcarotidarchaneurectomy.AnnAnat1994;176:333;
with
Page119of203
permission.)
FIG.179.
Neckdissectionofthehuman.Alargevagalvein(V)drainsvenousbloodtothesuperior
(S)andinferior(I)thyroidveins.Interruptiontothesevesselsinthyroidectomymay
accountforvagaldamageleadingtovoicechanges.ThevagusnerveisindicatedbyN.
(ModifiedfromFernandoDA,LordRSA.Thebloodsupplyofthevagusnerveinthe
human:itsimplicationincarotidendarterectomy,thyroidectomyandcarotidarch
aneurectomy.AnnAnat1994;176:333;withpermission.)
FIG.180.
Page120of203
Neckdissectionofthehuman.Theprominentvagalvein(V)drainsintotheinferior
thyroidvein.Thevagalarteryarisingfromtheinferiorthyroidarteryliesalongsidethe
vein.Suturesplaceddistaltothepointofopeningofthevagalveinorthecommencement
ofthevagalarterymayresultindegenerativechangesoredemaofthevaguswith
consequentvagalpalsy.ThevagusnerveisindicatedbyN.(FromFernandoDA,Lord
RSA.Thebloodsupplyofthevagusnerveinthehuman:itsimplicationincarotid
endarterectomy,thyroidectomyandcarotidarchaneurectomy.AnnAnat1994;176:333;
withpermission.)
FIG.181.
Page121of203
Dissectionoftheleftsideoftheneckandthorax.Thelargevagalartery(A)arises
fromtheinferiorthyroidartery.Thisvesselbifurcatesintoascendinganddescending
branches.Thedescendingbranchreceivesreinforcingtwigsfromtheaorta,bronchial,
andesophagealarteries.Damagetothesesmallvesselsinthyroidectomiesandremoval
ofaneurysmsoftheaorticarchmayalsocontributetovagaldamageandconsequent
symptomsofvagalpalsyandvoicechanges.ThevagusnerveisindicatedbyN;common
carotidarterybyB.(ModifiedfromFernandoDA,LordRSA.Thebloodsupplyofthe

vagusnerveinthehuman:itsimplicationincarotidendarterectomy,thyroidectomyand
carotidarchaneurectomy.AnnAnat1994;176:333;withpermission.)
Accordingtothesameauthors,thecervicalandthoracicpartsofthevagushaveasingle
largevagalartery,mostcommonlyontheanteromedialsideofthenerve,whichis
formedbycontributionsatseverallevels.Superiorly,thevagusreceivesabranchfrom
theposteriorinferiorcerebellarartery.Inferiorly,itissuppliedbyabranchfromthe
inferiorthyroidartery(themaintrunkofthevagalartery).Inbetween,thevagusreceives
reinforcingtwigsdirectlyfromthecommoncarotidandinternalcarotidarteriesat1.5cm
intervals.Thevagalveinsdrainintothesuperiorandinferiorthyroidveins.Vagalpalsy
followsapproximately27%ofcarotidendarterectomies.Thetypeofdamagetothevagus
nerveiscomparabletothatofthespinalcordwithinterruptionofradicularbranches.
Page122of203
FernandoandLord187alsowrotethatligatingtheinferiorthyroidarteryclosetoits
originwillinterrupttheprincipalsupplytothevagus(whichtypicallyarises23cmfrom
theinferiorthyroidsorigin).Ligationofthevenousdrainageofthenerveresultsin
edematouschangesandnervepalsy.
RecurrentLaryngealNerve
Inaseriesofthyroidoperationsinwhich217recurrentlaryngealnerveswereinvolved,
Holtandcoworkers188found9nerveinjuries,ofwhich4werepermanent.Inthesame
seriestherewerethreeinjuriestosuperiorlaryngealnerves;onewaspermanent.
Mostrecurrentlaryngealnerveinjuriesoccurjustbelowthatpointwherethenerve
passesunderthelowerfibersoftheinferior
constrictormuscletobecomeintralaryngeal.189Theusualcauseisahemostatic
stitch.137Anothersourceofinjuryismassligationofthevesselsofthelowerpoleofthe
thyroid.Suchligationmayincludearecurrentnervemoreanteriorthanusual.Thenerve
shouldbeidentifiedbeforeligatingtheinferiorthyroidvein.Thespecificcausesof
recurrentlaryngealnerveinjuryhave
beenevaluatedbyChangChien190(Table19).Table19.RecurrentLaryngealNerve
Vulnerability
CauseofVulnerability
PercentEncountered
Lateralandanteriorlocation
1.53.0
Tunnellingthroughthyroidtissue
2.515.0
Fascialfixation
2.03.0
Arterialfixation
5.012.5
Closeproximitytoinferiorthyroidvein
1.52.0+
DatafromsixseriesofChangChienY.Surgicalanatomyandvulnerabilityofthe
recurrentlaryngealnerve.IntSurg65:23,1980.

Theresultsofinjurytotherecurrentlaryngealnerveandtheexternalbranchofthe
superiorlaryngealnervehavebeenoutlinedbyEsmeraldoandcoworkers.191
Inunilateralrecurrentnerveinjury,theaffectedvocalcordisparamedianinposition
duetotensiononthevocalligamentbythecricothyroidmuscle.Voiceispreserved(not
unchanged).
Withunilateralinjurytoboththerecurrentlaryngealandsuperiorlaryngealnervethe
affectedcordisinanintermediateposition,resultinginhoarsenessandinabilitytocough.
Theaffectedcordwillmovetowardthemidlinewithtime.Voiceimproves,butis
followedbynarrowingoftheairway.Lossofthesuperiorlaryngealnerveleavesthe
tissuesofthelarynxandpiriformrecessesinsensate,resultinginlossofthecoughreflex
anddifficultieswithaspirationandclearingtheairway.Withbilateralrecurrentnerve
injury,becauseofthenarrowingoftheairwayproducedbyunopposedcricothyroid
muscles,
Page123of203
tracheostomybecomesnecessary.
Scanlonandcolleagues186reportedaseriesinwhich6of245patientswhohad
undergonetotalthyroidectomyexperiencedrecurrentlaryngealnerveparalysis.Allbut
onerecoveredwithinayear.
Postoperativehoarsenessisnotalwaystheresultofoperativeinjurytolaryngealnerves.
From1to2percentofpatientshavea
paralyzedvocalcordpriortothyroidoperation.188NeelandcoworkersattheMayo
Clinic192examined202casesofvocalcordparalysis,ofwhich153(76percent)
followedthyroidectomy,36(18percent)wereofvariousknownetiologies,and13(6
percent)wereofidiopathicorigin.Westronglyadvisethegeneralsurgeontohavean
indirectlaryngoscopyperformedpriortothyroidectomy.
Miyauchietal.133performedansacervicalisrecurrentlaryngealnerveanastomosisin
theneckforvocalcordparalysisduetomediastinallesions.Theyreportedexcellent
improvementinphonationwithoutvocalcordmovement.
Webelievethatthepatientshouldbetoldthatinspiteofallprecautions,thereisa
possibilitythattheremaybesomevocaldisabilityfollowingthyroidectomy.Dysphagia
canresultfromdamagetoearlyrisingbranchesoftherecurrentlaryngealnerves
thatsupplytheesophagus.193SuperiorLaryngealNerve
Lekacosetal.194noted3casesofsuperiorlaryngealnerveinjuryafter54classicalhigh
ligationsofthesuperiorthyroidartery.Theyobservedthatpatientswithlossofthe
externallaryngealnervecomplainedofvoiceinstability,quickvocalfatigueandinability
toproducehighpitchedsounds,withdifficultyinsinging.Noinjurieswererecordedin
227othercasesinwhichthe
branchesofthesuperiorthyroidarterywereligatedatthesuperiorpole.Accordingto
DurhamandHarrison,195theexternallaryngealnervecloselyparallelsthesuperior
thyroidvesselsinabout20%ofcases,andevenpassesbetweenthebranchesofthe
superiorthyroidarterynearthesuperiorpolein614%ofcases.

Intheirexcellentmonograph,JohnsandRood196discussedclassificationofthe
paralyzedvocalcord.Theparalyzedvocalcordmaybeparamedian(interruptionofthe
recurrentlaryngealnervealone[WagnerGrossmanntheory])orintermediate
(interruptionoftherecurrentandsuperiorlaryngealnerves).Injurytothesuperior
laryngealnervealonecanbeidentifiedbyrotationofthesuperiorglottistotheaffected
side,andbybowingofthevocalcord.
WeagreewiththestatementofJohnsandRood:
...Athoroughunderstandingoftheanatomyofthelarynxandtherelationshipsofthe
laryngealnervesupplytotheintrinsicmusclesofthelarynxisaprerequisitetoadequate
localizationofthesiteoflesioninlaryngealnerveinjury.Successful
managementofthepatientisbaseduponanaccurateetiologicdiagnosis.196
CervicalSympatheticChain
Asympatheticganglioncanbeconfusedwithalymphnodeandcanberemovedwhen
thesurgeonoperatesformetastaticpapillarycarcinomaofthethyroid.Inoneofour
patients,inferiorcervicalandfirstthoracicgangliawerefusedtoformanodelike
structurethatwasremoved.197Thesurgeonmustidentifyanyapparentlymphnode
relatedtothevertebralarteryandfixedinfrontofthetransverseprocessofthe7th
cervicalvertebra.
InjurytothecervicalsympatheticnerveresultsinHornerssyndrome:(1)constrictionof
thepupil,(2)partialptosisoftheuppereyelid,(3)apparentenophthalmos,(4)dilatation
oftheretinalvessels,and(5)flushinganddryingofthefacialskinontheaffectedside.
Thyroidectomyoflargegoiterswillbefacilitatedbydivision(high,middleorlow)ofthe
infrahyoidmuscles.Theexpectationisthatinjurytotheansacervicaliswillthusbe
avoided.HighdivisionwasrecommendedbyFarquharsonandRintoul198and
Page124of203
PaparellaandShumrick,199middledivisionbyWilson,200andlowdivisionbyStell
andMaran.201
Theformationandlocationoftheansacervicalisisvariable.Wehaveseenasingular
rootinonecase,whichisararephenomenon.Inmostcases,therearetworootswhich
unite;segmentalbranchesspringfromthisunion.Thepathwayofthesebranchesisquite
variable;thereforethereisnotypicalsegmentalinnervationoftheinfrahyoidmuscles.
Thesternohyoidandsternothyroidmusclesareinnervatedbybranchesthatspringafter
theunionoftheupperdescendentroot(C1)andthelowerdescendentroot(C2,C3)of
theansacervicalis(Fig.182).Theentranceofthemotorbranchofthesetwomusclesis
characteristicallyinthevicinityofthethyroidcartilage,andjustabovethejugularnotch,
or,rather,bisectingtheanglebetweentheinferiorsegmentofthesternohyoidmuscleand
theclavicle.
FIG.182.
Aplanoftherighthypoglossalnerveandansacervicalis.
Forallpracticalpurposeswedonotknowthetopographyoftheunionandthepathway
ofthebranchesoftheansacervicalisinagivenpatient.Therefore,wemustprepare
carefullyforfacilitatingthyroidectomybyunilateralorbilateraldivisionofthefour

infrahyoidorstrapmuscleswhichareinnervatedbytheventralramiofC1,C2andC3
viathehypoglossalnerve(Fig.183).The
musclesshouldordinarilybedividedhightoprotecttheirnervesupply.Byallmeanswe
agreewithBeahrsetal.23thattheintegrityofthesefourmusclesshouldbepreserved.
Page125of203
FIG.183.
Theansacervicalis,itsroots,anditsbranchestotheinfrahyoidmuscles.
Inourpracticesweoccasionallydividethemuscles;thepointofdivisionvaries
dependingonthesizeofthemegathyroid.Whileourpostoperativeobservationsmight
havebeensuperficial,wenevernoticedanychangesinvoice,deglutition,ormastication.
Whenthesefourmusclesareparalyzed,thehyoidboneandlaryngealapparatus
malfunctionandimpairswallowing.
Westronglyadvisetheinterestedstudenttocarefullyreadthepapersof
Yerzingatsian.202,203
Chaoetal.204reportedthattheuncommonprocedureofreoperativethyroidsurgerycan
besafelyperformedwithlittlemorbiditytothepatient.Postoperativecomplicationswere
asfollows:
Transienthypoparathyroidism
5.2%
Permanenthypoparathyroidism
1.7%
Transientrecurrentlaryngealnervepalsy
2.6%
Page126of203
Permanentrecurrentlaryngealnervepalsy
1.7%
WequotefromProfanteretal.205onprimaryhyperparathyroidism(HPTH):
Sonographyhadanoverallaccuracytocorrectlylocalizeenlargedparathyroidglandsof
80%,andscintiscanninghadoverallaccuracyof78.6%.Theaccuracyoflocalizationwas
increasedupto84.6%ifbothdiagnosticprocedureswereapplied.Inpatientswithnormal
thyroidresiduestheaccuracyofsonographywas85.7%,anditwas100%if
scintiscanningwasused...Preoperativelocalizationtechniquesinpatientswithprimary
HPTHandpreviousthyroidsurgeryhavehighaccuracy.Thisallowsforanimaging
directedoperativestrategy,thuspreventingunnecessarybilateralneckexplorations,
whichcarryahighriskofrecurrentlaryngealnerveinjury.
WequotefromMenegauxetal.aboutsecondarythyroidectomy:206
Thepermanentcomplicationrateishigherinthyroidreoperationsthaninprimarythyroid
operations.However,webelievethat
this2%rateislowenoughtoallowreoperationwheneveritisnecessary,provided
preciseoperativerulesarerespected.
ParathyroidGlands
EmbryogenesisNormalDevelopment

Inthefifthandsixthweeksofgestationtheembryonicpharynxismarkedexternallyby
fourbranchialcleftsofectoderm.Internallytherearefivebranchialpouchesof
endoderm.Thesecleftsandpouches,togetherwiththebranchialarchesbetween,
composethebranchialapparatus.Althoughtransitory,theapparatusleavessomenormal
derivatives:thethyroidandparathyroidglands,thymus,ultimobranchialbody,eustachian
tube,middleear,andexternalauditorycanal.Thereisalsothepossibilitythatsome
normallytransientstructureswillpersistintoadulthood.
Theparathyroidglandsdevelopasepithelialthickeningsofthedorsalendodermofthe
thirdandfourthbranchialpouches.Asaresultoftheirsubsequentmigration,the
derivativesofthethirdpouchbecometheinferiorparathyroids(parathyroidsIII),while
thoseofthefourthpouchbecomethesuperiorparathyroids(parathyroidsIV)(Fig.184).
Bothprimordiadescendfromtheirleveloforigin,butparathyroidsIIIareclosely
associatedwiththethymusglandderivedfromtheventralportionofthethirdpouch.
Thisassociationusuallyendsintheeighthweek,leavingtheparathyroidglandnearthe
levelofthelowerborderofthethyroidgland.Occasionally,parathyroidsIIIbecome
encapsulatedwiththethymusandmaybecarriedintothemediastinum.Thisisofno
significancetothepatient,butitmaybefrustratingforthesurgeon.
FIG.184.
Page127of203
Themigratorypathwaysoftheparathyroidglands.Theglandsmaybefoundatany
pointalongthosepathways,usuallyatthelevelsindicatedbythehorizontalarrows.
(ModifiedfromGraySW,SkandalakisJE,AkinJTJr.Embryologicalconsiderationsof
thyroidsurgery:Developmentalanatomyofthethyroid,parathyroid,andtherecurrent
laryngealnerve.AmSurg1976;42:621628;withpermission.)
Thefollowingpointsareimportanttoconsider:
Isthegenesisoftheparathyroidglandsofectodermalorigin,andthereforefrom
pharyngealclefts3and4?Maybe.Dotheparathyroidglandsarisefromtheneuralcrest,
meaningtheybelongtotheAPUDsystem?Maybe.
Lundgrenetal.207demonstratedthattheabnormalparathyroidtissueofnormocalcemic
primaryhyperparathyroidismischaracterizedbymorphologicandfunctional
derangements.Theseareconsistentlyseeninpatientswithprimaryhyperparathyroidism
andhypercalcemia.
CongenitalAnomalies
Abnormalparathyroiddevelopmentincludesvariationsinlocation,number,shape,size,
weight,andcolor.Parathyroidcystsmaybecongenital.TheLobdellDiGeorgesyndrome
(agenesisoftheparathyroidandthymus)isananomalywhichinvolvesthecaudad
branchialarchesandpouches,andpresentswithapproximately38combinations.
Figure185illustratestheanatomiclocationsofectopicparathyroidglandsfoundina
studybyShenetal.208TheprocedureforlocatingsuchglandsispresentedinStrategy
forFindingParathyroidGlandslaterinthischapter.Casasetal.,209Malhotra
etal.,210andMartinetal.211advisedpreoperativeparathyroidlocalizationwith
technetium99msestamibiscan.Thisnotonlymayreduceoperativetime,butalsomay
contributetosuccessfulsurgery.

FIG.185.
Page128of203
Anatomiclocationsofectopicparathyroidglands,withnumberfoundineach
location(n=54).(ModifiedfromShenW,DurenM,MoritaE,HigginsC,DuhQY,
SipersteinAE,ClarkOH.Reoperationforpersistentorrecurrentprimary
hyperparathyroidism.ArchSurg131:861869;withpermission.)
SurgicalAnatomy
GeneralTopographicAnatomy
Theparathyroidglandsareusuallyfoundontheposteriorsurfaceofthethyroidgland,
eachwithitsowncapsuleofconnectivetissue.Theyareoccasionallyincludedinthe
thyroidcapsule,oroneofthemmayevenfollowabloodvesseldeepintoasulcusofthe
thyroid.
Thefrequencyofsuchoccultglandsisnotknown.Farrandassociates212found10
examplesamong100patientswithparathyroidtumors.Fewintrathyroidparathyroid
glandsarediscoveredintheabsenceofdisease.Severaltechniqueshave
beendevelopedforlocatingoccultparathyroidglands.213,214
McIntyreetal.215reportedthat18of309patients(6%)whohadundergone
parathyroidectomyhadintrathyroidalparathyroid
glands.Libuttietal.216reportedanintrathyroidalparathyroidglandin7percentofthe
casesandtheyadviseultrasonographyforselectionofpatientsforthyroidresection.
Grayetal.217tabulatedtheadultpositionof200parathyroidglandsin50cadavers.
Table110showsthelocationoftheseglands,allofwhichcouldbeconsidered
normal.
Table110.LocationofParathyroidsin50Cadavers
Page129of203
LocationonThyroidGland
SuperiorParathyroids,%
InferiorParathyroids,%
Upperthird
8
2
Middlethird
80
12
Lowerthirdorbelowinferiorpole
12
86
100
100
Extremelocationsareveryrare,althoughglandshavebeenfoundashighasthe
bifurcationofthecarotidarteryandaslowas

themediastinum.139Inpractice,thesurgeonshouldstartatthepointatwhichthe
inferiorthyroidarteryentersthethyroidgland.Thesuperiorparathyroidglandswill
probablylieaboutoneinchaboveit,andtheinferiorparathyroidglandswillprobablylie
onehalfinchbelowit.Iftheinferiorglandisnotfound,itismorelikelytobelowerthan
higher.
Typicallytherearefourparathyroidglands,butitisfairlycommontohavemoreor
fewer.Whenfewerthanfourglandsarefound,thepossibilityofectopicglandsishardto
ruleout.Twoparathyroidglandscanbefusedtooneanother;suchapaircan
bedifferentiatedfromabilobateglandbythepresenceofacleavageplanebetween
them.139
Hoogheetal.218reportedthatin416parathyroidectomies,19%oftheorganswerefound
inectopiclocations,suchasdistanttothethyroidlobes,alongtheesophagus,orinthe
upperanteriormediastinumwithinthymicremnants.AmongHooghespatients,5%had
supernumeraryparathyroids.Parathyroidtissuewithinthethymuswithprimary
hyperthyroidismwasreported
byWeietal.219
McHenryetal.220studiedparathyroidlocalizationwithtechnetium99msestamibi,and
reportedthatthesensitivityandpositivepredictivevalueofthisscintigraphictechniqueis
comparabletoorbetterthanotherlocalizationprocedures.Thesameauthorsreported
thatthetestslackofsensitivityforthedetectionofmultiglandulardiseaseprecludesits
useforbilateralroutineexplorationinpatientswithhyperparathyroidism.
AlthoughCT,MRI,andtechnetium99m/thallium201havebeenusedforidentifyingthe
glandsprimaryhyperparathyroidism,
thesearchcontinuesforbetterimagingmodalities.Bonjeretal.221exploredthe
possibilityofusing2methoxyisobutylisonitrile(MIBI)labeledwithtechnetium99m
scanningasapreoperativeandintraoperativetechniqueusingahandheldgammaprobe.
DespitethefactthatBonjerandcolleaguesconcludedthattheMIBIprobedidnot
improvetheoutcomeofparathyroidsurgery
intheirstudy,weagreewiththeinvitedcommentaryofLinos221thatthereisroomfor
improvementofthistechniqueandthat
theprobeshouldcontinuetobeused.Indeed,Purcelletal.222havereportedahigh
degreeofsuccessusingacombinationofhighresolutionultrasoundandtechnetiumTc99
sestamibiscanningtolocatetheparathyroidsbeforesurgeryinpatientswith
hyperparathyroidism.
EditorialCommentHighresolution3dimensionaltechnetium99msestamibiscansare
justcomingintouseandearlyexperiencesuggeststhattheyareusefulinlocatinga
solitaryglandandpermittinglimitedparathyroidexplorationforexcisionofthesingle
glandinovertwothirdsofthepatientswithprimaryhyperparathyroidism.(RogerS.
Foster,Jr.,MD)
Szaboetal.223foundinaretrospectivestudyof659patientswithsporadicprimary
hyperparathyroidismthattheincidenceof
Page130of203
parathyrodidadenomaintwoenlargedparathyroidglandswasapproximately12%.

EditorialCommentThisreportofahighrateofapparentdoubleadenomas223is
consistentwithotherreports.Itisnotatallclear,however,thattherateofdouble
functioningadenomasisanywherenearashigh.Ifthefirstenlargedglandistrulyan
adenoma,ratherthanhyperplastic,thesesecondsmallerenlargedglandsmaybenon
functional.Inselectedpatientsthecureratesreportedafterunilateralexplorationand
excisonofadenomashavebeenveryhigh.TherecentdevelopmentofaquickPTHassay
forintraoperativeusemayhelpdeterminethephysiologicsignificanceofdouble
adenomas.(RogerS.Foster,Jr.,MD)
Preoperativelocalizationofparathyroidadenomasisevenmoredifficultwhenthyroid
nodulesarepresent.Krauszetal.224advisethatintheabsenceofthyroidpathology,
highresolutionultrasonographyshouldbethefirststepforlocalizationofaparathyroid
adenomapriortosurgery.Theyreportedthatinpatientswithprimary
hyperparathyroidismalone,scintigraphywithtechnetium99msestamibiisaneffective
diagnostictool.Scintigraphyandultrasonographyareneededwhenthepatienthas
thyroidabnormalitiesinadditiontohyperparathyroidism.
VascularSupply
Alveryd225studiedparathyroidarterialsupplyin354autopsyspecimens.Itwas
observedthatboththesuperiorandinferiorparathyroidsareusuallysuppliedbythe
inferiorthyroidartery:86.1%ontherightside,76.8%ontheleft.Intheabsenceofan
inferiorthyroidartery,boththesuperiorandinferiorparathyroidglandsweresuppliedby
thesuperiorthyroidarteryinthe
majorityofcases225(Fig.186,Table111).Afterastudyof160autopsyspecimens,
Wang139statedthatthevascularpediclecouldbeusedtolocatealowlyingparathyroid
IV(Fig.187).
Table111.VariationsinVascularSupplyof1405ParathyroidsIdentifiedat354
Autopsiesa,b
RightSide
LeftSide
1Parathyroid
23Parathyroids
Total
1Parathyroid
23Parathyroids
Total
Inferiorthyroidartery
12.4c
86.4
98.8
20.1c
76.8
96.9
Superiorthyroidartery
8.7
0.6

9.3
15.0
2.8
17.8
Thyroidimaartery
0.6
0.6
0.6
0.6
Arteryfromlarynx,trachea,esophagus,ormediastinum
1.7
1.7
2.0
2.0
aFromAlverydA.Parathyroidglandinthyroidsurgery.ActaChirScand1968;389
(suppl):1120.
bThefiguresindicatethefrequencyinpercentoftotalnumberofcases.
cIncludes10cases(rightside)and13cases(leftside)inwhichonlyoneglandwas
Page131of203
identified.
FIG.186.
Page132of203
A,Schematicdrawingsshowingthepositionsoftheparathyroidglandsandtheir
vascularsupplyin12caseswith5parathyroidswithoutadenoma.Therightandleft
parathyroidsareindicatedseparatelyineachcase.B,Variationsinthelocationofthe
parathyroidglandsinrelationtotheinferiorarteryonbothsidesin354caseswith25
glands.Theschematicdrawingsshowalateralviewofthelarynxandtracheawiththe
thyroidmobilizedanddislocatedventrallyandmedially.Dottedhorizontallinesindicate
thelevelsoftheentranceoftheuppermostandlowermostbranchesoftheinferiorartery
inthethyroidparenchyma.Thehatchedareasindicatethelocationoftheparathyroids.
Forthesakeofcompleteness,thecaseswithoutaninferiorthyroidarteryarealso
registeredinseparatedrawings,butinthesethelocationoftheparathyroidisnotshown.
Page133of203
(ModifiedfromAlverydA.Parathyroidglandinthyroidsurgery.ActaChirScand
(suppl)1968;389:1120;withpermission.)
FIG.187.
A.AtoC.Anatomicdistributionof312upperparathyroidglands(parathyroidIV).B.A
toD.Anatomicdistributionof312lowerparathyroidglands(parathyroidIII).(Modified
fromWangC.Theanatomicbasisofparathyroidsurgery.AnnSurg1976;183:271;with
permission.)

Asnotedpreviously,Noborietal.109foundthatabranchfromthesuperiorthyroidartery
thatanastomosedwiththeinferiorthyroidarterysuppliedthesuperiorparathyroidgland
inapproximately45%ofcases.Thegreaterfrequencyofsupplybythesuperiorthyroid
arteryseenintheworkofNoborietal.incontrasttothatofotherscouldbeattributable
tothetechniquesusedorperhapstogeneticdifferencesinanatomy.
Delattreetal.226foundthatthebloodsupplytotheparathyroidsseemstooriginateas
follows:Superiorparathyroids:
77.1%Inferiorthyroidartery
15.3%AnastomosisofinferiorandsuperiorthyroidarteriesInferiorparathyroids:
90.3%Inferiorthyroidartery
Page134of203
Anderetal.227studiedthebloodsupplyandparathyroidhormonesecretioninpatients
withparathyroidadenomaorsecondaryhyperplasia.Theyreportedthat,despite
devascularization,increasedparathyroidhormonesecretionremainedunchanged.
Innervation
Theinnervationoftheparathyroidglandsiseitherdirectfromthesuperiorormiddle
cervicalganglia,orthroughaplexusinthefasciaontheposteriorlobaraspects.
HistologyandPhysiology
Themajorportionoftheparathyroidparenchymaisformedbytheprincipalcellsanda
minorpartisformedbyoxyphiliccells.Perhapsalltheparathyroidcellsparticipateinthe
secretionoftheparathyroidhormone,parathormone(PTH),andintheregulationof
calciumandphosphatemetabolism.Westronglyadvisetheinterestedstudentofthe
parathyroidstoreadthe
excellentpaperofWeberetal.,228whichsuggeststhatthePTHcontentofparathyroid
tissuemaybeofuseindifferentiatingnormalfromabnormalorgans.
Tomaintainnormalcalciumintheblood,afeedbacksystemisformedbetweenthe
circulatingcalciumandthesecretionofPTH.Toomuchserumcalciuminhibits
productionofPTH;toolittlestimulatessecretion.
Cisnerosetal.229statedthatinpatientswithnonmetastaticsquamouscellcarcinomaof
theskin,humoralhypercalcemiaofmalignancy(tumorhormonesecretionintothe
systemiccirculationdistanttotheskeletonwithsubsequentboneresorption)canbe
producedbyparathyroidhormonerelatedprotein(PTHrP).
WequotefromPerezandPazianos230:
[T]heabsenceofanelevatedPTHlevelinthepresenceofhypercalcemiashouldexclude
primaryhyperparathyroidismasthecause.Rarely....thePTHlevel,althoughinthe
normalrange,isconsideredtoohighfornonparathyroidhormonemediatedcauseof
hypercalcemiaotherthanprimaryhyperparathyroidism.Tothebestofourknowledge,
themediatorinvolvedintheparathyroidglandsofthesesubjectsisunknown.
However,weagreewithLiVolsi231whostatedthatourunderstandingofparathyroid
pathophysiologyisfarfromcomplete.Assuggestedbytheauthorsofthisstudy,
informationfrommolecularbiologystudiesofcalciumsensingreceptorsandthegenes
regulatingcalciumsensitivityinparathyroidtissue(bothnormalandabnormal),remains
tobedefined.

SurgeryoftheParathyroids
Themostcommonindicationforparathyroidsurgeryishyperparathyroidism.Veryrarely
parathyroidcystsareassociatedwithhyperparathyroidism,butthesecystshavenever
beenfoundtobemalignant.
AcaseofafunctioningparathyroidcystwaspresentedbySafran;232thisreviewstated
thatMitmakerreportedonly162casesofparathyroidcystsintheliteraturein1991,with
alowerincidenceoffunctioningcysts.Safranrecommendedaspirationofthesecysts,
whichpresentasmassesatthelateralorlowerneck.Hypercalcemia,hypophosphatemia,
andelevatedserumparathormonearealwayspresent,butdisappearaftertheremovalof
thecyst.
EditorialCommentThecystscontainwaterclearfluidandthatisakeytothediagnosis
onaspirationofaneckmass,asthyroidcystsarenotwaterclear.Theparathyroid
hormoneiselevatedinthecystfluidbutnotintheblood.(RogerS.Foster,Jr.,MD)
Malignancyoftheparathyroidsis,ofcourse,rarebutmayinvolveoneormore
parathyroids.Surgeonsshoulddecideintheoperatingroomhowradicalaprocedurethey
willuseandwhetherremovalofadjacentanatomicentitiesisnecessary.
StrategyforFindingParathyroidGlands
Page135of203
Thenormallocationofthesuperiorandinferiorparathyroidglandshasbeendescribed.
Traynoretal.233foundthatrapiduptakeofmethylenebluebytheparathyroidglands
suggeststhatselectiveintraoperativeusewhenglandsaredifficulttolocate
intraoperatively,ratherthanaroutinepreoperativeinfusion,ispossiblewithout
significantoperativedelay.Generalsurgeonsmusttakespecificstepstofindtheglands,
however,becausetheycannotexploretheentireneck.Thefollowingstepsare
essentiallythosesuggestedbyAdams,234Cady,235McGarityandBostwick,236and
Edis:237
Step1.Explorethesuperiorsurfaceofthethyroidgland.Ligatethemiddlethyroidveins,
retractthelobemediallyandanteriorly,
andexposetherecurrentlaryngealnerve.
Step2.Dissectthesuperiormediastinumasfaraspossible,withspecialattentiontothe
thymusoritsremnantbehindthemanubrium.
Step3.Exploretheregionabovetheupperpoleofthethyroidglandasfarasthehyoid
bone.
Step4.Exploretheretroesophagealandretropharyngealspaces.
Step5.Performsubtotalthyroidectomy.
Step6.Furtherexplorethemediastinumatasecondoperation.Thisshouldbedoneonly
afterthepathologyreportonthymusandthyroidtissuehasbeenreceivedandno
parathyroidtissueisreported.236
Theorderofthesesteps,especiallysteps5and6,iscontroversial.Inaseriesof400
operationsreportedbyNathanielsand
colleagues,238therewere84mediastinalparathyroidtumors.Ofthese,19required
mediastinotomy.Sixtysevenwereintheanteriormediastinum,and17wereinthe

posteriormediastinum.Theremainderwereremovedthroughaneckincision.Webelieve
mediastinalexplorationshouldbetheprocedureoflastresort.
SurgicalApplications
Preoperativelocalizationoftheparathyroidglandsisatremendoushelpforbothpatient
andsurgeon.Guptaetal.239advisethatpreoperative99mtechnetiumsestamibi(MIBI)
localizationofsimpleparathyroidadenomawithhyperparathyroidismswillreducenot
onlyoperativetimebutalsotheextentofsurgicaldissectionandrisk.
Farneboetal.240statedthatKi67(cellcycleassociatedantigen)maygivevaluable
informationastothemalignantpotentialofparathyroidtumors,whereasretinoblastoma
proteinimmunoreactivityhasnotprovenusefulindistinguishingbetweenbenignand
malignantparathyroidtumors.
Ryanetal.241statedthatafterlocalizationoftheparathyroidadenomaaunilateralneck
explorationproducesresultssimilartobilateralexploration,andrequireslessoperative
time.
Angelosetal.242reportedaveryunusualcaseofapatientwithhyperparathyroidism
whoexperiencedspontaneousleftrecurrentlaryngealnerveparalysisafterwhichhis
hypercalcemiaresolved.Afterremovalofaparathyroidadenomawithabscessformation
thevocalcordfunctionreturned.
Richardsetal.243reportedtheninthcaseofspontaneousinfarctionofaparathyroid
adenomainprimaryhyperparathyroidism.Theanatomyoftheinfarctionisenigmatic.
Theaboveauthorsspeculatethatperhapstheinfarctionissecondarytothetumor
outgrowingitsbloodsupply.Thrombosisoftheparathyroidbloodsupplywasreported
by
Dowlatabadi.244
Billingsleyetal.245usedthetermparathymictodesignateanundescended
parathyroidglandthatislocatedhighintheneckjustbeloworabovethecarotid
bifurcation.Embryologicallythetermiscorrect,sincetheinferiorparathyroidsandthe
thymusarisefromthethirdpharyngealpouch.However,thetermwillconfusethe
surgeonwhoisnotfamiliarwiththe
Page136of203
ontogeniclocationoftheparathyroidglandsandwhomaythinkitreferstoathymic
locationoftheparathyroid.
Forthetreatmentoffamilialhyperparathyroidism,Barryetal.246advisedsubtotal
parathyroidectomyandroutinetranscervicalthymectomy.
Proyeetal.247statedthatpatientswithprimaryhyperparathyroidismandmultiple
glandenlargementmaybetreatedbyconservativesurgery,resectingonlythegrossly
enlargedglandsandnotbiopsyingthenormallookingglands.
Chenetal.248reportedthatparathyroidectomyinelderlypatients(over70years)can
beperformedwithhighcures,lowmorbidity,nomortality,shortlengthofstay,andhigh
patientsatisfaction.
PasiekaandParsons249reportedthatparathyroidectomyreducespreoperative
symptomatologyinpatientswithprimaryhyperparathyroidism,withthemostmarked
improvementoccurringwithinthefirst10daysaftersurgery.

RyanandLee250emphasizedtheeffectivenessandsafetyof100consecutive
parathyroidectomiesinnormalizingserumcalcium.
Angelos251studiedpatientswithprimaryhyperparathyroidismwhowereevaluatedby
preoperativescintigraphy.Afterexcludingseveralpatientsbasedontheirhistories,the
remainingpatientswithpositivescansunderwentsuccessfulradioguidedoperations,
whilethosewithnegativescanshadsuccessfulstandardparathyroidectomies.Angelos
concluded,"Althoughradioguidedparathyroidsurgeryisaneffectivesurgicalapproach...
[s]tandardfourglandexplorationwillcontinuetobeneededformanypatients."
Miccolietal.252recommendedendoscopicparathyroidectomyafterpreoperative
localizationofparathyroidlesionsandintraoperativeparathyroidhormoneassay.They
hadgoodresultsin39patients.
Starretal.253reportedthatintraoperativemeasurementofintactparathyroidhormone
tomeasureadequacyofresectionofhyperfunctioningtissueduringparathyroidectomy
decreasedtheharvestingoffrozensections,butdidnotimprovetherateofnormalization
ofserumcalcium.
Zaracaetal.254statedthattotalparathyroidectomywithautotransplantationin19
patientswithseveresecondary(renal)parathyroidismrelievesthehyperthyroidism
symptoms,andtherecurrencerateofhyperparathyroidismislow.
MollerupandLindewald255statedthatprimaryhyperparathyroidismandrenalstone
diseasearecommon,butanumberofpatientsexperiencerecurrenceoftheirstone
diseaseinthepresenceofnormalcalciumratesaftersuccessfulparathyroidectomy.
Caccitoloetal.256believethatthecorrectionofpostexplorationhypocalcemiausing
cryopreservationandautotransplantationissoundintheory,butdifficultinpractice.
Sincehyperparathyroidismmaydevelopafterautotransplantationofhistologically
normalparathyroidtissue,oraftera
periodofpostsurgicalhypoparathyroidism,D'Avanzoetal.257stressestheimportanceof
markingthesiteofparathyroidtransplantation.
Usingendoscopiclasertechnology,Stojadinovicetal.258removedaparathyroid
adenomawhichwaslocatedinthepiriformrecess.
Althoughlongperiodsofremissionarepossibleaftersubtotalparathyroidectomy,
Burgessetal.259reportedthatrecurrenthyperparathyroidismeventuallydevelopsin
mostpatientswithmultipleendocrineneoplasiatypeI(MENI).
RatesofsuccessfulsurgeryforprimaryhyperparathyroidismareshowninTable112.
Page137of203
Kikumorietal.260reportedthatgraftingoftheparathyroidswithtotalthyroidectomy
issuccessfulandthattheglandsfuctionforalongtime.
Table112.SuccessfulSurgeryforPrimaryHyperparathyroidism
Procedure
SuccessRate
Investigator
Initialoperation
95%
Clarketal.351

Edisetal.352
Martinetal.353
Granbergetal.354
Reoperationwithoutlocalizationpriortosurgery
60%
Satavaetal.355
Reoperationwithlocalizationpriortosurgerybynoninvasivetechniques
89%
Grantetal.356
NOTE:AccordingtoCheungetal.357andSuggetal.,358invasivetechniquessuchas
arteriographyandselectivevenoussamplingfailtolocalizetheabnormalparathyroid
gland.
AnatomicComplicationsofParathyroidectomy
Thecomplicationsofparathyroidectomyarethesameasthoseassociatedwith
thyroidectomy(previouslyconsideredinthischapter)andradicalnecksurgery(tofollow
laterinthischapter).261,262
Failuretofindanadenomatousglandinthepresenceofhyperparathyroidismisevidence
ofaninadequateprocedure.HellstromandIvemark263reportedfailuretofindthe
diseasedglandin10percentof92patients.
Toavoidrepeatedparathyroidectomies,Shenetal.208advisedbilateralcervical
explorationandpreoperativelocalization.
LoandLam264advisedimmediateautotransplantationofparathyroidglandstoavoid
hypoparathyroidism.Thesameauthors
cautionedthatroutineautotransplantationwasassociatedwithahighincidenceof
postsurgicalhypocalcemia.265Bergeretal.266statedthefollowing:
Thereisamarkedheterogeneityinglandsizeinpatientswithsporadicmultigland
hyperplasia,whichissimilartothatfoundinmultipleendocrineneoplasiatypeI.This
heterogeneitymayresultinfailuretorecognizemultiglanddiseaseifaunilateralneck
explorationisperformed.Intraopertiveparathyroidhormoneassaymayprovetobean
importantadjunctinthispopulationofpatientswhohaveunsuspectedmultiglanddisease.
Page138of203
TracheaattheNeck
EmbryogenesisNormalDevelopment
Thereisconfusionintheliteratureregardingtheuseofthetermsventralanddorsalwall
oftheforegut.Remember:therespiratorydiverticulumappearsattheventralwallofthe
foregut,butbyseparationlaterandtheformationoftheesophagopharingealborder,the
foregutisdividedintwoportions:ventral,whichisresponsibleforthegenesisofthe
respiratorysystem,anddorsal,whichisresponsibleforthegenesisoftheesophagus.
Attheendofthethirdweekofgestation,thelaryngotrachealgrooveappearsonthe
ventralsurfaceoftheupperendoftheembryonicforegut.Thedistalendofthegroove
growscaudad,whiletheproximalendandtheforegutgrowcephalad.Thetrachea
(anterior)andtheesophagus(posterior)becomeseparatedcaudally;inthefourthweek,
thelungbudsappearatthetipofthetrachealprimordium.Atfirstthetrachealbifurcation

ishighinthecervicalregion;atbirthitwillbeatthelevelofthe4thor5ththoracic
vertebra.
Cartilageappearsinthetracheaandprimarybronchiinthetenthweek,andglandsappear
aweeklater.267,268
CongenitalAnomalies
Thetracheaisrarelysubjecttoanomalies.Tracheoesophagealfistulaistheonlydefect
frequentlyencountered.Itsrepairdoesnotfallintothefieldofthegeneralsurgeon.
VascularcompressionofthetracheawasreportedbyBurchetal.269
SurgicalAnatomy
GeneralStructure
Thetrachea,togetherwiththeesophagusandthyroidgland,liesinthevisceral
compartmentoftheneck.Theanteriorwallofthecompartmentiscomposedof
sternothyroidandsternohyoidmuscles.Itiscoveredanteriorlybytheinvestinglayerof
thedeepcervicalfasciaandposteriorlybythepretrachealfascia(seeFig.126).The
tracheabeginsatthelevelofthesixthcervicalvertebra.Itsbifurcationisatthelevelof
thesixththoracicvertebraintheerectposition,orthefourthtofifththoracicvertebrae
whensupine.
Thereare16to20trachealcartilages.Thecervicalpartofthetracheaconsistsof4or5
incompleteringsofcartilageandtheirconnectingmembranes,smoothmusclefibers,and
fibroelastictissuecompletingthearchesposteriorly.Thesmoothmusclefibersare
arrangedhorizontally,attachingtotheperichondriumoftheendofthecartilage.Inthis
way,contractionofthemusclenarrowsthelumenofthetrachea.Theposteriorsurfaceof
thetrachea,formedbythefibromuscularmembrane,isthereforeflat.
Thecartilagesareabout4mmhighandabout1mmthick.Insomecasesthecartilagesof
twoormoreringsfuse,usuallyonlypartially.Insomecasestheendsofthecartilagemay
bifurcate.Thehighestofthetrachealringsisattachedtothecricoidcartilagebythe
cricotrachealmembrane.Thisisthewidestofthetrachealcartilages.Thediameterofthe
tracheaisgreaterinmenthaninwomen,andisquitesmallinearlychildhood.
Asubcutaneoustoughbandcoveringthelaryngealmucosaextendsfromthecricoid
cartilagetothethyroidcartilageandtothevocalprocessesofthearytenoidcartilages.
Thisisthecricothyroidmembraneorligament,thesiteofemergency
cricothyroidostomy.
ThesurgicalanatomyofthecricothyroidmembranewasstudiedbyDoveretal.,270who
emphasizedtheimportanceofknowledgeofthepathwayofthecricothyroidartery(Fig.
188).Theystatedthatin93percentofindividuals,thisarteryarose
Page139of203
fromthesuperiorthyroidartery;itcrossedtheupperonehalfofthecricothyroid
membranein14outof15cadavers.Incricothyroidostomytheseveredcricothyroid
artery,oranastomosingbranches,maybleedunseendirectlyintothetrachea,with
possibleaspirationanddeath.Theauthorsalsoidentifiedseveralveinscrossingthe
membrane.Theirfindingsonthedimensionsofthecricothyroidmembraneareseenin
Figure189.
FIG.188.

Cricothyroidartery(arrow)traversingupperportionofcricothyroidmembrane.
(ModifiedfromDoverK,HowdieshellTR,ColbornGL.Thedimensionsandvascular
anatomyofthecricothyroidmembrane:relevancetoemergentsurgicalairwayaccess.
ClinAnat1996;9:291295;withpermission.)
FIG.189.
Page140of203
Dimensionsofcricothyroidmembrane.Rangeand(mean)valuesreportedin
millimeters.(ModifiedfromDoverK,HowdieshellTR,ColbornGL.Thedimensions
andvascularanatomyofthecricothyroidmembrane:relevancetoemergentsurgical
airwayaccess.ClinAnat1996;9:291295;withpermission.)
VascularSupply
Arteries
Thechiefsourcesofarterialbloodtothetracheaaretheinferiorthyroidarteries.Atthe
trachealbifurcation,thesedescendingbranchesanastomosewithascendingbranchesof
thebronchialarteries.
Veins
Smalltrachealveinsjointhelaryngealveinoremptydirectlyintotheleftinferiorthyroid
vein.Theinferiorthyroidveinsariseasavenousplexusontheanteriorsurfaceofthe
isthmusofthethyroidgland.Leftandrightdescendingveinsentertherespective
brachiocephalicveins(seeFig.158).Thetwoveinsmayformacommontrunkentering
thesuperiorvenacavaortheleftbrachiocephalicvein.
Page141of203
Lymphatics
Thepretrachealandparatracheallymphnodesreceivethelymphaticvesselsfromthe
trachea.
Innervation
Thetrachealismuscleandthetrachealmucosareceivefibersfromthevagusnerve,
recurrentlaryngealnerves,andsympathetictrunks.Smallautonomicgangliaare
numerousinthetrachealwall.
HistologyandPhysiology
Thehistologyandphysiologyofthetracheaiscoveredbrieflyinthechapteronthe
respiratorysystem.
SurgeryoftheTrachea
Thefollowingarethemostcommonproceduresperformedonthetrachea:
Tracheostomy
Resectionofmalignanttumors(primaryorsecondary)orbenigntumors
Associatedbenignormalignanttrachealcompressionfortumorsclosetothetrachea
relatedanatomicentitiesTreatmentoftrachealstenosis
Treatmentoftracheoesophagealfistulas(multipleprocedures,seechapteron
esophagus).
AnatomicLandmarksandRelations

Theusualsiteofatracheostomyisbetweenthe2ndand4thor3rdand5thtrachealrings.
Severalstructuresareencountered.
Beneaththeskin,theplatysmaliesinthesuperficialfasciaandisabsentinthemidline.
Theanteriorjugularveinsmaylieclosetothemidline;moreimportantly,theymaybe
unitedbyajugularvenousarchattheleveloftheseventhtoeighthtrachealringsinthe
suprasternalspaceofBurns.
Theinvestinglayerofdeepcervicalfasciaisencounteredwhenthesuperficialfasciais
reflected.Deeptotheinvestingfasciaarethesternohyoidandsternothyroidmuscles.
Thesemusclesliebetweentheinvestinglayerandthepretrachealfasciaoneithersideof
themidline.Theyareretractedlaterally.
Thereareseveralstructureswithinthevisceralcompartmentunderthepretrachealfascia.
Theisthmusofthethyroidglandcommonlyliesatthelevelofthesecondandthird
trachealrings;itisfrequentlymorecranial,lessfrequentlymorecaudal.Theisthmuscan
beretractedupwardordownwardtoreachthetrachea;ifnecessary,itcanbeligatedand
incised.Inabout10percentofindividuals,thetwolobesofthethyroidarenotconnected
byanisthmus.
Thepossibilityofathyroidimaarteryshouldnotbeforgotten.Asuspensoryligamentof
thethyroid(seeDeepFascia:PretrachealLayerdescribingthefasciaeoftheneck
previouslyinthischapter)andalevatorthyroidmusclemayalsobepresentin,orclose
to,themidline.
IndicationsforTracheostomy
Tracheostomyisperformedfollowingextensiveoperativeproceduresupontheneck
whenpostoperativelaryngealedemaexists,orasaconcurrentprocedurewhenatotal
laryngectomyisperformed,orfollowingseverefacialtrauma.Itmayalsobeperformed
asanemergencyproceduretoestablishanairwaywhenthereisobstructionbyaforeign
body,laryngealedemaorpostoperativevocalcordparalysis.Itcanbeperformedeither
aboveorbelowtheisthmusofthethyroidgland,althoughthelowerapproachisusually
preferable.Theisthmuscanberetractedsuperiorlyordividedbetweenhemostats.
Ahookisusuallyplacedbeneaththecricoidcartilageinthemidlinetostabilizethe
tracheaandpullitforward.Theincisionin
Page142of203
thetracheacanbeperformedeitherinverticalorhorizontalfashion;usually,however,
the3rd,4th,and5thtrachealringsaredividedverticallyfromabovedownward.Today,
themajorityofsurgeonstakeawindowoutofthe2ndor3rdring.Theincisionisheld
openforinsertionofthetracheostomytube.Itisimportanttoselectatubeoftheproper
sizesothatpressureofthetubewillnotcausenecrosisoftheposteriortrachealwall.
Afterevaluatingtracheostomyin76pediatricburnpatients(newborntothreeyearsof
age),Colnetal.271concludedthatpediatrictracheostomymaybeperformedsafely
withoutcomplicationsandwithacceptablechronicmorbidity.
Whenemergencytracheostomyisindicated,theprocedureofchoiceis
cricothyroidostomy.Theprocedureisverysimple.Afterlaryngealstabilization,theskin
andsubcutaneoustissueareincisedbyashortverticalincision.Themembraneis
palpatedandincisedtransversely,thendilated.Thetracheostomytubeisinserted.

Maipangetal.272performedmediastinaltracheostomiesin12patientswithadvanced
carcinomaofthelowerneckandsuperiormediastinum.
AnatomicComplications
TracheostomyGeneralPrecautions
GerandEvans273relatedtheanatomiccomplicationsoftracheostomytotheageofthe
patientandthelocationofthestoma.Neonatesandinfantshavemorecomplications.The
sameauthorsdescribedthecomplicationsthatoccurwhentracheostomyisperformed
aboveorbelowtheisthmus.Theanatomiclandmarkisthe1sttrachealring,whichis
identifiedbelowthelowerborderofthecricoidcartilageandabovetheupperborderof
theisthmus.Ofcourse,thisdependsuponthethicknessandwidthoftheisthmus.
Thespacebetweentheisthmusandthesuprasternalnotchisatthelevelofthe2ndor3rd
trachealringsaboveandthe4thor5thtrachealringsbelow.Hightracheostomycan
producetrachealstenosis;lowertracheostomycanalsoproduceagalaxyofanatomic
complicationsinadultsandchildren.
EditorialCommentTraditionalsurgicaltracheostomycanindeedbeperformedinthe
patientsbed,andmaynotbedemonstrablymoredifficultforthepatient,butitismore
uncomfortableforthesurgeon.Theoperativefieldisfartherawayandcreatesan
uncomfortablepostureforthesurgeon.Lightingmaybelessthanideal.
Theproblemmaybeobviatedbyusinganendoscopicorultrasoundguidedpercutaneous
tracheostomytechnique.Percutaneoustracheostomyshouldbeasimplerinbed
procedurethanopensurgicaltracheostomy.(RogerS.Foster,Jr.,MD)
REMEMBER
Thebrachiocephalicarteryinadultsliesanterolaterallytotherightofthetracheaand
veryclosetothetrachealstoma.FatalbleedingfrominjurywasreportedbySilenand
Spieker,274Yangetal.,275andTakano.276
Knowthelocationoftheleftbrachiocephalicvein.Inchildren,theveinislocatedatthe
lowestpartoftheneck,justabovethemanubrium.Inadults,itislocatedbehindthe
sternumattheupperhalfofthemanubrium.
Inferiorthyroidveinsandthethyroidimaarteryarelocatedattheanteriorwallofthe
trachea.Theyshouldbeligatedtoavoidbleeding.
Divisionofthethyroidisthmusisagoodtechniqueforavoidingcomplications.
Combinedinjuriesofthetracheaandesophagusshouldberepairedprimarily.The
sternocleidomastoidmusclecanbeusedbetweenthetworepairedorgans.277
Page143of203
Upadhyayetal.278reportedthattracheostomycansafelybeperformedwithout
transportingthepatienttotheoperatingroom.Theirstudyof470patientsshowedno
significantdifferenceincomplicationsbetweenthe311patients(8.7%)whounderwent
bedsidetracheostomyandthe159patients(9.4%)whounderwentoperatingroom
tracheostomy.
Ifadrainisused,itshouldbebroughtoutthroughastabwoundontheoppositesideof
theneck.
VascularInjury
Thefollowingalertsyoutoseveralvesselsthatmaybleedduringtracheostomy.279

Theanteriorjugularveinsmaybeencounteredastheinvestingfasciaisincised.
Thevenousthyroidplexusoverthethyroidglanddrainsintothethyroidveins.The
inferiorthyroidveinsdraininferiorlyintothebrachiocephalicveins,eitherforminga
singlestemordrainingseparately.Theinferiorthyroidveinisoftenasymmetric,hence,
moreliabletoinjury.
Thebranchesofthesuperiorandinferiorthyroidarteriesmayanastomoseacrossthe
midline.Athyroidimaarteryisveryoccasionallypresent,andmustbeligatediffound.
Thebrachiocephalicarteryandleftbrachiocephalicveincanbeinjuredifsharp
dissectioniscarriedtoofardownward.Thearterycanbeerodedbyatracheostomytube,
resultinginatracheoarterialfistula.
Thesubclavianarteryandveincanbecompromisedbyatracheostomytubethatis
incorrectlycurvedorplacedtoolow(Fig.190).
Thecommoncarotidarterycanbeinjuredwhenattemptingatracheostomyinthe
newborn.Moreover,ithasbeenmistakenforthetrachea.Theleftcommoncarotidartery
mayarisefromthebrachiocephalictrunk,thereaftercrossingthelowerpartofthe
cervicaltrachea.
FIG.190.
Tracheostomytubes:A,Tubetoocurved.Thetrachealwallmaybeerodedandthe
subclavianarterymaybeoccluded.B.Tube
Page144of203
placedtoolow.Subclavianvesselmaybeoccluded.C,Tubewithcorrectcurvature
correctlyplaced.(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.Anatomical
ComplicationsinGeneralSurgery.NewYork:McGrawHill,1983;withpermission.)
OrganInjury
ESOPHAGUS
Injurytotheesophagususuallyoccursnotfromerrorsofperceptionoftheanatomy,but
fromerrorsintheuseofthetracheostomytube.Itispossible,however,tocreatean
iatrogenictracheoesophagealfistulabycarelessmanipulation.280
PNEUMOTHORAXANDPNEUMOMEDIASTINUM
Pneumothoraxandpneumomediastinumalsohavebeenreported.
RECURRENTLARYNGEALNERVES
Injurytothesenervescanoccurduringtracheostomyaswellasduringthyroidectomy
(seeAnatomicComplicationsofThyroidectomy).
LARYNX
Toohighatracheostomycanresultindirectinjurytothevocalcords.Placementofthe
tubethroughthethyrohyoidmembranecanalsoproducevocalcordinjury.279Thestoma
shouldbeformedbelowthefirstring.
POSTTRACHEOSTOMYSWALLOWINGDYSFUNCTION
Theadverseeffectofacuffedtracheostomytubeontheswallowingmechanismwas
studiedbyBonanno.281Evaluationofthemaxillary,glossopharyngeal,recurrent,and
externallaryngealnervesrevealedthatnerveinjurywasnotafactor.Bonannoconcluded
thatthedysfunctionwasproducedbyinhibitionofelevationandanteriorrotationofthe
larynxandbyfailureofthehypopharyngealsphinctertoopencompletely.

InadequateProcedures
Anappreciationoftheangleofthetracheatothesurfaceoftheneckisimportantin
selectingatubewiththepropercurvature.Thedistalendofatubewithtoomuch
curvaturewillerodetheanteriortrachealwall.185Roe282recommendeda60degree
curvature(Fig.190).
Cricothyroidostomy
Theanatomiccomplicationsofcricothyroidostomyareasfollows:
Bleeding
Pneumomediastinum
SubcutaneousemphysemaChangeofvoice
Paresisofthevocalfold
Laryngealfracture
Dysphonia
Subglotticstenosis
Page145of203
SalivaryGlandsIntroduction
Themajorsalivaryglands(parotid,submandibular,andsublingual)areshowninFig.1
91.FIG.191.
Salivaryglandsandtheirducts.Dissectionshowingthesublingual,submandibular
(submaxillary),andparotidglands.Deeplateralviewofthelingualregionwiththebody
andpartoftheramusofthemandiblecutawaytoexposetheglandsandrelated
Page146of203
structures.(ModifiedfromAnsonBJ(ed).MorrisHumanAnatomy(12thed).New
York:McGrawHill,1966;withpermission.)Salivarychoristomas,hamartomas,
embryonicrests,anddisplacedsurfaceglandswithinalveolarbonemaydevelopinto
intraosseoussalivaryneoplasms.283
Haetal.2reportedanunusualsalivaryglandchoristomainthemiddleearspacewhich
appearedtobeadevelopmental
abnormalityassociatedwithabnormalitiesofadjacentstructures.
ParotidGlands
Embryogenesis
NormalDevelopment
Earlyinthesixthweekofdevelopment,theparotidductappearsasasolidoutgrowthof
theoralepithelium.Itgrowsposteriorly,towardtheear,investingthefacialnerve(VII)
withitsbranches.Thesolidcordssubsequentlybecomecanalized,andthecellsatthetips
ofthebranchesdifferentiateintosecretoryacini.
CongenitalAnomalies
Congenitalabsenceofmajorsalivaryglandsisrare.MartinezSubiasetal.285reported
totalagenesisoftheparotidgland.
Accessoryglandulartissueseparatedfromthemainglandisnotrare.Parotidtissuemay
extendforwardbetweenthetwopterygoidmuscles(pterygoidlobe)anduponthe

massetermuscle(accessorylobe),andoccasionallyformsevenmoremediallyonthe
buccinatormuscle.
WeagreewithAnsonandMcVay286thataccessorytissueiscommon(20%).Most
commonisalocalaggregationofglandulartissue(thesociaparotis)alongtheparotid
duct,intowhichthesmallductsoftheaccessorytissueempty.Theseaccessoryparotid
tissueshavetheirownbloodsupplyfromthetransversefacialartery.
SurgicalAnatomy
GeneralRelations
Theparotidglandliesbeneaththeskin,infrontofandbelowtheear.Itiscontained
withintheinvestinglayerofthedeepfasciaoftheneck,calledtheparotidfascia.Itis
separatedfromthesubmandibularglandbyafascialthickening,thestylomandibular
ligament.
Theparotidglandoccupiestheparotidspace,theboundariesofwhichare:
Anterior:Massetermuscle,ramusofthemandible,andmedialpterygoidmuscle
Posterior:Mastoidprocess,sternocleidomastoidmuscle,andposteriorbellyofthe
digastricmuscleandfacialnerve
Superior:Externalauditorymeatus,andtemporomandibularjoint
Inferior:Sternocleidomastoidmuscle,andposteriorbellyofthedigastricmuscle
Lateral:Investinglayerofthedeepcervicalfascia,skin,andplatysmamuscle
Medial:Investinglayerofthedeepcervicalfascia,styloidprocess,internaljugularvein,
internalcarotidartery,andpharyngealwall
Fromtheanterolateraledgeofthegland,theparotidduct(Stensens)passeslateraltothe
massetermuscle.Itturnsmedialattheanteriormarginofthemuscle,whereitisrelated
tothebuccalfatpadorbouledeBichat(Fig.192).Thebuccalpadis
locatedmedialtotheparotidduct,betweenthemasseterandbuccinatormuscles.287The
buccinatormuscleispiercedbythe
Page147of203
duct.Itenterstheoralcavityattheleveloftheuppersecondmolartooth.Accessory
parotidtissuemayextendalongtheparotidduct.Ashortaccessoryductmayenterthe
mainduct.286,287
FIG.192.
Theanatomicrelationsofthebuccalpadoffat.(ModifiedfromTostevinPMJ,EllisH.
Thebuccalpadoffat:areview.ClinAnat1995;8:403;withpermission.)
Someauthors41,77describedthreesurfaces(lateral,anterior,andposterior),three
borders(anterior,medial,andsuperior),andtwoextremities(superiororbase,and
inferiororapex).
Therehaslongbeencontroversyaboutthelobesoftheparotidgland.Twoimportant
studies,whichbothappearedin1956,
illustratetheproblem.Davisandcoworkers288concludedthatthereisasuperficiallobe
andadeeplobeofthegland;the
branchesofthefacialnerverunbetweenthem.Incontrast,WinstenandWard289
visualizedtheglandasessentiallyunilobar;thebranchesofthefacialnerveare
intimatelyenmeshedwithintheglandtissue,withnocleavageplanebetweenthenerve

andgland.Beahrs23agreedwiththeunilobarconcept,asdidHollinshead.36Theview
thatoneacceptsdoesnotchangethesurgicalprocedureofsuperficialparotidectomy.
Poncetetal.290statedthatthesurgicaldivisionoftheparotidglandinto3parts,or
lobes,inrelationtothefacialnerveisapracticalcustom.Wehaveseenonelobe,or
twolobes(superficialanddeep).Wethinkthatthesocalledthirdorfourthlobesare
nothingbutembryologicparotidsegments.
ParotidFascia
Theparotidfasciaisthesplittingofthegeneralinvestinglayerthatenvelopsboththe
parotidandsubmandibular(submaxillary)glands,formingthesuperficialanddeep
layers.Thesuperficiallayerisdenseandtoughincomparisontothedeep,whichisthin
andweak.However,thestylomandibularligamentbetweenthestyloidprocessandthe
angleofthemandibleisderivedfromthedeeplayer.Itistough,andseparatestheparotid
fromthesubmandibulargland.
Theparotidspacecommunicatesmediallywiththelateralpharyngealspaceandwiththe
posteriorareaofthemasticator
Page148of203
space.Theposteriorareaofthemasticatorspacecontainsthemassetermuscle,the
pterygoidmuscles,thesmallpterygomandibularspaceandthespaceofthebodyofthe
mandible.
Sincemanyintraparotidanatomicentitiesradiatefromthegland,thesurgeonshouldbe
familiarwithallofthem,especiallythosethatmustnotbesacrificed.
BEDOFTHEPAROTIDGLAND
Completeremovaloftheparotidglandrevealsthefollowingstructures(theacronym
VANSmaybehelpfulinrememberingthem):
OneVein:internaljugular
TwoArteries:externalandinternalcarotid
FourNerves:glossopharyngeal(IX),vagus(X),spinalaccessory(XI),hypoglossal
(XII)
FouranatomicentitiesstartingwithS:styloidprocess,andstyloglossus,
stylopharyngeus,andstylohyoidmuscles.
ThetopographyofVANSisasfollows:
Theinternaljugularveinislocatedmedialtothestyloidprocess,positionedposteriorly.
Occasionallytheexternalcarotidarteryisembeddedwithinthedeeplobe,butusuallyit
issuperficial.Theinternalcarotidarterycanbefoundanteriortotheinternaljugular
vein.
Thestyloidprocessinadultsisapproximately2.5cmlonganditstipislocatedbetween
theexternalandinternalcarotidarteries,justlateraltothetonsillarfossa.Anelongated
styloidprocess(calledEaglessyndromebecauseEagledescribeditin1937)cancause
throat,neck,orfacialpain.
Theglossopharyngealnerve(IX)snakesaroundthestylopharyngeusmuscle,spiraling
arounditsposteriorsurfaceasitpassesinferiorlyandmediallytothewallofthepharynx.

Thevagusnerve(X)islocatedunderor,occasionally,betweentheinternaljugularvein
andtheinternalcarotidartery.Theoriginofthesuperiorlaryngealbranchisfoundinthis
vicinity.
Thespinalaccessorynerve(XI)issuperficialandlateraltothecarotidsheath.
Thehypoglossalnerve(XII)islocatedsuperficialandmedialtothecarotidsheath.
InadditiontothestyloidprocessarethemusclesbeginningwithS:thestyloglossus
andstylopharyngeus,whicharebeneaththeexternalcarotidartery,andthestylohyoid,
whichisaboveit.
VascularSupply
ARTERIES
Theexternalcarotidartery(Fig.193)enterstheinferiorsurfaceoftheglandanddivides
attheleveloftheneckofthemandibleintothemaxillaryandsuperficialtemporal
arteries.Thelattergivesrisetothetransversefacialartery.Eachofthesebranches
emergesseparatelyfromthesuperiororanteriorsurfaceoftheparotidgland.
FIG.193.
Page149of203
Diagrammaticrepresentationoftherelationshipoftheparotidglandtothebranches
oftheexternalcarotidartery.(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.
AnatomicalComplicationsinGeneralSurgery.NewYork:McGrawHill,1983;with
permission.)
NOTE:Anarterywhichhasnothingtodowiththeparotidisthemiddlemeningeal
artery:itisabranchofthemaxillaryarterywhicharisesslightlyanteriortotheneckof
themandibleintheinfratemporalfossa.Itentersthecranialcavitythroughtheforamen
spinosumandsuppliesbloodtotheduramaterwithintheskull.
VEINS
Thesuperficialtemporalvein(Fig.194)entersthesuperiorsurfaceoftheparotidgland.
Itreceivesthemaxillaryveintobecometheretromandibularvein.Stillwithinthegland,
theretromandibularveindivides.Theposteriorbranchjoinstheposteriorauricularvein
toformtheexternaljugularvein.Theanteriorbranchemergesfromtheglandtojoinwith
thefacialvein,therebyformingthecommonfacialvein,atributarytotheinternal
jugular.Remember:thefacialnerveissuperficial,thearteryisdeep,andthe
retromandibularveinliesbetweenthem.
FIG.194.
Page150of203
Diagrammaticrepresentationoftherelationshipoftheparotidglandtotributariesof
theexternalandinternaljugularveins.(ModifiedfromSkandalakisJE,GraySW,Rowe
JSJr.AnatomicalComplicationsinGeneralSurgery.NewYork:McGrawHill,1983;
withpermission.)
LYMPHATICS
Thepreauricularlymphnodesinthesuperficialfasciadrainthetemporalareaofthe
scalp,upperface,lateralportionsoftheeyelids,andanteriorpinna.Parotidnodeswithin
theglanddraintheglanditself,aswellasthenasopharynx,nose,palate,middleear,and

externalauditorymeatus.Thesenodes,inturn,sendlymphtothesubparotidnodesand
eventuallytothenodesoftheinternaljugularveinandspinalaccessorychains(seeTable
12).
Marks291discussedthenumberoflymphnodesintheparotidarea.Hereportedfinding
1to11lymphnodesin17specimensofradicalparotidectomy.Hisopinionisthat
perhapsasignificantnumbermaybeleftintheskinflaps.
Innervation
AUTONOMICNERVOUSSYSTEM
Theparotidglandisinnervatedbytheparasympatheticandsympatheticdivisionsofthe
autonomicnervoussystem.
Theparasympatheticinnervationoftheparotidglandoriginatesfromthe
glossopharyngealnerve.Itstympanicbranch(thenerveofJacobson)ascendsintothe
skullthroughasmalltympaniccanaliculustoreachthemiddleear,whereitentersinto
theformationofanerveplexusonthepromontoryofthemedialwallofthemiddleear
cavity.Thisplexusconsistsofamixtureofsensory(pain)andautonomicfibers.The
lesser(superficial)petrosalnerve(Fig.195),consistingofpresynapticparasympathetic
neurons,emergesfromthisplexus,leavesthemiddleearcavity,travelsacrossthefloor
ofthemiddlecranialfossa,andthendescendsthroughtheforamenovaletoreachtheotic
ganglion.Theoticganglionissuspendedfromthemandibularnerve,justinferiortothe
foramenovale.Thepresynapticparasympatheticfibersofthelesserpetrosalnerve
synapseupontheneuronswithintheoticganglion.Thepostsynapticparasympathetic
fibersleavetheganglion,formingoneof
Page151of203
thetworootsoftheauriculotemporalnerve,whichpassoneithersideofthemiddle
meningealartery,neartheforamenspinosum.Severalbranchesoftheauriculotemporal
nervepassintotheparotid,carryingpostsynapticparasympatheticfiberstotheglandular
units.Someofthesefibersaredeliveredtothesecretoryunitsbybranchesofthefacial
nerveasitpassesthroughthegland.Theparasympatheticfibersaresecretomotor;when
stimulatedbysensory(orpsychic)stimuli,thesefibers
elicitprofuse,waterysecretionofthegland(Fig.196).Last292hasabeautifuland
pragmaticexpressioninwhichhestatedthatthesecretomotorfibersreachtheglandby
hitchhiking.
FIG.195.
Schemaoftheparasympatheticinnervationoftheparotidgland.Solidline,preganglionic
pathway.Brokenline,postganglionicpathway.
FIG.196.
Page152of203
Secretomotornervetoparotidgland.(ModifiedfromBasmajianJV,SloneckerCE.
GrantsMethodofAnatomy[11thed].Baltimore:Williams&Wilkins,1989;with
permission.)
ThesympatheticsupplytotheparotidoriginatesfromspinalcordsegmentsT1T3(Fig.
197).Fibersfollowthevertebralrootsofthethreeupperthoracicnerves,thentravelvia

whiteramicommunicantestotheuppersympatheticthoracictrunkandupwardtothe
cervicalsympathetic,reachingthesuperiorcervicalganglion.Fromthis,branchestravel
towardtheexternalcarotidarteryformingasympatheticplexus,whosefibersfollowthe
branchesoftheexternalcarotidtoreachtheparotidgland.Theprimaryfunctionofthe
sympatheticsystemmaybevasoconstriction.
FIG.197.
Page153of203
Sympatheticsupplytotheparotidgland.WRC,whiteramicommunicantes.
AURICULOTEMPORALNERVE
Theauriculotemporalnerve,abranchofthemandibulardivisionofthetrigeminalcranial
nerve,carriespostganglionicparasympatheticfiberstotheparotidgland.The
preganglionicparasympatheticfibersfortheparotidarecarriedinitiallybythe
glossopharyngealnerveanditslesserpetrosalbranch;thepostganglionicsariseintheotic
ganglion,justoutsidetheskull,deeptothemainstemofthemandibulardivisionofthe
trigeminalnerve.Inaddition,theauriculotemporalnerveissensorytotheexternalear
andearcanal,temporomandibularjoint,andskinofthetemporalpartoftheface.It
traversestheupperpartoftheparotidglandandemergeswiththesuperficialtemporal
bloodvesselsfromthesuperiorsurfaceofthegland(Fig.198).
FIG.198.
Page154of203
Diagrammaticrepresentationoftherelationsoftheparotidglandtothefacialnerve
anditsbranches.(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.Anatomical
ComplicationsinGeneralSurgery.NewYork:McGrawHill,1983;withpermission.)
Withinthegland,theauriculotemporalnervecommunicateswiththefacialnerve.The
auriculotemporalnerveis,forallpracticalpurposes,sensoryandsecretory.
Usuallytheorderofthestructuresfromthetragusanteriorlyis:theauriculotemporal
nerve,superficialtemporalarteryandvein,andtemporalbranchofthefacialnerve.
RELATEDNERVES
Twonervesthatarerelatedtotheparotidgland,butdonotinnervateit,arethefacial
nerveandthegreatauricularnerve.FacialNerve
Thefacialnervehasnothingtodowithparotidinnervation,butwepresentthenervehere
becauseofitsverycloserelationshipwiththeparotidandsalivaryglands.
Themaintrunkofthefacialnerve(Fig.198)enterstheposteriorsurfaceoftheparotid
glandabout1cmfromitsemergencefromtheskullthroughthestylomastoidforamen,
aboutmidwaybetweentheangleofthemandibleandthecartilaginousearcanal.
Itisimportanttorememberthatatbirththechildhasnomastoidprocess;the
stylomastoidforamenissubcutaneous.Therefore,thefacialnervespositionmakesit
particularlyvulnerable.
About1cmfromitsentranceintothegland,thefacialnervetypicallydividestoform
fivebranches:temporal,zygomatic,buccal,mandibular,andcervical.Inmost
individuals,aninitialbifurcationcalledthepesanserinusformsanuppertemporofacial
Page155of203

andalowercervicofacialdivision,butsixmajorpatternsofbranching,basedona
seriesofsimpletocomplexarrangements,havebeendistinguished.288
Ingeneral,thenerveanditsbrancheslieinaplanedividingthedeepandsuperficial
portionsofthegland,butthereisnotruefascialplanebetweentheseportions.
Beahrs23suggestedthefollowingmethodtoidentifythefacialnerve:Thelowertipof
themastoidprocessispalpatedandafingertipisplacedonthelateralsurfacepointing
forward.Thetrunkofthefacialnervewillbefounddeepandanteriortothecenterofthe
fingertip.
Theeasiestmethodofidentificationtakesalateralapproach.Theinsertionofthe
posteriorbellyofthedigastricmuscleisidentified.Thenerveisjustmedialtothe
insertionpoint.
Thestyloidprocessisanunreliablelandmarkbecauseofvariationsinitsshapeandsize.
Otherlandmarksforlocatingthefacialnervehavebeensuggested,e.g.,theexternal
auditorycanal293andthetympanomastoidsuture.294,295
GreatAuricularNerve
Thegreatauricularnervearisesfromthesecondandthirdnervesofthecervicalplexus.It
reachestheposteriorborderofthesternocleidomastoidmusclenearthejunctionofthe
upperthirdandlowertwothirdsofthemuscle(Erbspoint).Thereafteritpasses
obliquelyupwardandforwardtotheintervalbetweentheearlobeandtheangleofthe
mandible,roughlyfollowingthecourseoftheexternaljugularvein(Fig.198).Itis
usuallysacrificedatparotidectomy.Numbnessinthepreauricularregion,thelower
auricle,andthelobeoftheearresultsfrominjurytothisnerve,butdisappearsafter4to6
months.
Insummary,thebranchesofthefacialnervemaybeapproximatedbyaradiatingseries
oflines,eachofwhichbeginsattheintertragicnotchoftheexternalear(Fig.199):
Temporalbranch:fromnotchtopointAhalfwaybetweenearandlateralangleofthe
eye
Zygomaticbranch:fromnotchtolateralangleofeye
Buccalbranch:fromnotchto.5cmabovethelabialtubercleoftheupperlip
Cervicalbranch:fromnotchtoapoint(B)halfwaybetweentheearlobeandtheangle
ofthemandibleMarginalmandibular:fromnotchtoapointabout1cmbelowthe
vascularnotchofthemandible
FIG.199.
Page156of203
Superficialdistributionofthefacialnerve.Schematicrepresentationofthetypical
positionsofthebranchesofthefacialnerveinrelationtovisibleorpalpabletopographic
featuresoftheface.A,indicatesthemidpointofalinebetweenthelateralangleofthe
eyeandtheanteriorsurfaceoftheear.Alinefromtheintertragicnotchasshownwill
overliethetemporalbranch.B,indicatesthemidpointofahorizontallinedrawnfromthe
angleofthemandibletojustbelowthelobeoftheear.Alinedrawnfromtheintertragic
notchtothismidpointoverliesthetypicalcourseofthecervicalbranch.
Thegreatauricularnervemaybeusedasanervegraft.

SurgeryoftheParotidGland
Aninflammatoryprocessoftheparotidproducesseverepainbecauseofthetough
unyieldingsuperficialparotidfascia,whichtriggerspainfiberscarriedbythe
auriculotemporalnerve.Sincetheparotidtissueextendsintotheretromandibulararea,
anymovementofthejawwillproduceseverepain.Remembertheprobablecauseof
parotiditis(the4Ds):debility,dehydration,depressedsalivation,anddirtymouth.
Abscessesmaybeformedsecondarytopharyngealperforationorbloodborne
infections.Stoneformationwithintheductandobstructionisanotheretiologyofabscess
formation.Thestonemaybepalpated(iflargeenough)withinthemouth.Theyielding
deepparotidfasciamayrupture;puswilltraveltotheretromandibularspace,
temporomandibularjoint,orexternalauditorycanal.Thisabscesscanbedrainedthrough
theoralcavityoroccasionallybyaverticalincisionoftheskinandelevationofthe
gland.
Page157of203
Chronicsclerosingsialadenitis,achronicinflammatoryconditionofthesalivary
glands(especiallythesubmandibular
gland)whichcannotbeclinicallydistinguishedfromatrueneoplasm,isalsoknownas
Kuttnertumor.Williamsetal.296reportedacaseofKuttnertumorofthesubmandibular
andparotidglandsexhibitingwidespreadswelling.
Tunkeletal.297statedthatHIVinfectionhasbroadmanifestationsaffectingthehead
andneck,andreported5seropositivepatientswithbilateralparotidenlargement.
Parotidtumorsmaybebenignormalignant.Mostofthebenigntumorsarelocatedin
thesuperficiallobeandshouldbeexcisednotbyenucleation,butbylobectomy.
Malignanttumorsshouldbetreatedbytotalparotidectomy;sacrificethefacialnerveifit
isinvolvedwiththeprocess.
WequotefromJamesandSharma298onparotidglandsarcoidosis:
Parotidglandsarcoidosisoccursin6%ofpatientswithsarcoidosis.Itwasbilateralin24
(73%),slightlycommonerinwomen,andpresentedinthemajorityinthe20to40year
agegroup.Therewaswidespreadinvolvementofothersystems,particularly
intrathoracic,peripherallymphadenopathy,uveitis,lacrimalglandenlargementandskin
disease.PatternsofinvolvementmaybepathognomicasinHeerfordt'sdisease.
Inpatientswithcarcinomaoftheparotidgland,Kelleyetal.299adviseneckdissection
onlyforthosehistologicdiagnosesthatcarrythehighestriskofnodalmetastasesandfor
thosepatientswhoseprimarytumorresectionmightbefacilitatedbylymphadenectomy.
Inotherwords,neckdissectionshouldbeperformedonlywhenthereareclinically
enlargednodesorwhenCTscangivesevidenceofnodalinvolvement.
Renehanetal.300analyzedtreatmentofpatientswithrecurrentpleomorphicadenoma
oftheparotidgland.Thosewithmultinodularrecurrencesareathighriskofrelapse;they
benefitfromsurgerywithradiotherapy.Patientswithuninodularrecurrencesmaybe
adequatelytreatedbysurgeryalone.Ararepleomorphicsalivaryadenomainan
adolescentwas
reportedbyFortyandWake.301

ThesyndromeofFrey(auriculotemporalnervesyndrome)consistsofgustatory
sweatingandflushingoftheipsilateralfacefollowingparotidectomy,penetrating
wounds,orinfectionoftheparotid.Thisconditionmaybecausedbystimulationofthe
preauricularsweatglands.Irregularregenerationinthedistributionofauriculotemporal
nervefiberscausesflushingandsweatingtotakeplacewheneating,tasting,orsmelling.
ThetreatmentofFreyssyndromeissectionoftheglossopharyngealnerve,which
suppliesthepreganglionicfibersfortheparotidgland.
Traumaintheparotidareacanproduceinjuryofthefacialnerveordivisionofthe
parotidduct.Microsurgeryistheprocedureofchoiceforboth.Ifthisisnotpossiblefor
theduct,proximalanddistalligationisacceptable.Forasalivaryfistula,radiationmay
beindicatedtoproduceatrophyofthegland.
Agraftcanbeusedforthefacialnerve,employingthefollowingnervesfordonortissue
segments:thegreaterauricular,ilioinguinal,lateralfemoralcutaneous,andsural.The
greatauricularisthebestbecauseitislocatedinthesameareaandbecauseitscaliberis
almostthesameasthatofthefacialnerve.
Rememberthatthefacialnerveissuperficial,aveinisunderthenerve,andthearteryis
deepest.
Mostofthetumorsoftheparotidarebenign;mostofthetumorsofalltheminor
salivaryglandsaremalignant.302Whythisissoisnotknown.
Themostcommonprocedureforabenigntumorisremovaloftheparotidlobe.
Enucleationofthetumorisverytempting,butitisthewrongprocedurebecauseofits
highrecurrencerate.Totalparotidectomyformalignanttumorsisthetreatmentofchoice
despitepossiblesacrificeofthefacialnerve.Withinflammatoryprocessandabscess
formationananatomicincisionfordrainingisadvised.
Page158of203
Northetal.303demonstratedtheefficacyofpostoperativeirradiationfor
improvingsurvivalandlocalcontrolinpatientswithcarcinomasoftheparotidand
submandibularglands.
Inareviewofpediatricneoplasmsofthemajorsalivaryglands,ShikhaniandJohns304
recommendedcompleteremovalofthetumoratinitialsurgery(Tables113,114,and1
15).
Westronglyadvisethesurgeoninterestedintreatmentofparotidandsalivarycancersto
studyworksofJohnsandcolleagues.305308
Table113.BenignSalivaryGlandNeoplasmsinChildren(229fromLiterature,18from
JohnsHopkins)
Histology
Number
Percent
Pleomorphicadenoma
214
86.6
Plexiformneurofibroma
8

3.2
Warthinstumor
5
2
Cystadenoma
5
2
Lymphoepitheliallesion
3
1.2
Neurilemmoma
3
1.2
Embryoma
3
1.2
Xanthoma
2
0.8
Adenoma
1
0.4
Total
247
100%
Source:ShikhaniAH,JohnsME.Tumorsofthemajorsalivaryglandsinchildren.Head
NeckSurg1988;10:257263;withpermission.
Table114.MalignantSalivaryGlandNeoplasmsinChildren(243fromLiterature,3
fromJohnsHopkins)
Histology
Number
Percent
Mucoepidermoidcarcinoma
122
49.6
Aciniccellcarcinoma
30
12.2
Undifferentiatedcarcinoma
22
8.9
Adenoidcysticcarcinoma
16
6.5

Adenocarcinoma
19
7.7
Page159of203
Malignantmixedtumor
10
4.1
Rhabdomyosarcoma
6
2.4
Undifferentiatedsarcoma
5
2.0
Mesenchymalsarcoma
5
2.0
Unclassifiedcarcinoma
4
1.6
Squamouscellcarcinoma
3
1.2
Lymphoma
3
1.2
Ganglioneuroblastoma
1
0.4
Total
246
100%
Source:ShikhaniAH,JohnsME.Tumorsofthemajorsalivaryglandsinchildren.Head
NeckSurg1988;10:257263;withpermission.
Table115.SummaryofTreatmentandOutcomeof272CasesinChildhoodSalivary
GlandNeoplasms
Histology
InititalTreatment
No.ofCases
Recurrence
NED(%)
DOD
FollowUp
41

8(19.5)
23/25(92)
0
129yrs
Pleomorphicadenoma(parotid)
Superiorparotidectomy
Totalparotidectomy
14
1(7.1)
14/14(100)
0
422yrs
Excision
56
22(39.3)
45/50(90)
1
149yrs
Pleomorphicadenoma
(submandibular)
Excision
21
4(19)
21/21(100)
0
325yrs
Superiorparotidectomy
13
4(30.7)
11/11(100)
0
217yrs
Mucoepidermoidcarcinoma
(parotid)
Totalparotidectomy
7
0(0)
7/7(100)
0
0.522yrs
Excision
41
20(48.8)
16/17(94.1)

1
114yrs
Excision&RT
5
0(0)
5/5
0
15yrs
(100)
Page160of203
(100)
Mucoepidermoidcarcinoma(submandibular)
Excision&RT
2
1(50)
2/2(100)
0
5.5&7yrs
Aciniccellcarcinoma(parotid)
Superiorparotidectomy
1
0(0)
1/1(100)
4yrs
Totalparotidectomy
2
0(0)
2/2(100)
0
2&3yrs
Excision
19
5(26)
6/7(85.7)
0
216yrs
Adenoidcysticcarcinoma(parotid)
Superiorparotidectomy
2
0(0)
2/2(100)
0
0.5&10yrs

Totalparotidectomy
4
2(50)
2/4(50)
2/4
0.518yrs
Excision
9
5(55.5)
3/7(42.8)
4/7
1051yrs
Miscellaneouscarcinoma*
Totalparotidectomy
2
1(50)
1(50)
1/2
2mos7yrs
Totalparotidectomy&RT
3
1(33.3)
2/3(66.6)
1/3
214yrs
Excision
10
8(80)
1/8(12.5)
7/9
9mos8yrs
Excision&RT
8
7(87.5)
1/6(16.6)
5/6
39mos
RTalone
2
2(100)
0(0)
2/2
412mos
Sarcoma(parotid)

Totalparotidectomy
3
1(33.3)
2/3(66.6)
1/3
722yrs
Totalparotidectomy&RT
3
3(100)
0
3
0.33yrs
Excision&RT
3
3(100)
0
3
68mos
RTalone
1
1(100)
0
1
15mos
Page161of203
*Miscellaneouscarcinomasundifferentiated,adeno,malignantmixed,andunclassified
carcinoma
NED,noevidenceofdisease;DOD,deadofdisease;RT,radiationtherapy.
Source:ShikhaniAH,JohnsME.Tumorsofthemajorsalivaryglandsinchildren.Head
NeckSurg1988;10:257263;withpermission.
AnatomicComplications
VascularInjury
Themajorvesselscrossingtheparotidbedmustbedividedandligatedduring
parotidectomy.Bleedingfromsmallvesselscanresultinhematoma.
NerveInjury
Themostcommonlyinjuredbranchesofthefacialnervearethebuccalandmandibular;
theyalsohavefewinterconnectionswithotherbranches.Thefacialnerveandits
branchesareobviouslyindangerduringparotidectomy.Theycanbepreservedonlyby
carefulobservationandawarenessofthepreviouslydescribedanatomy.Astimulating
electrodecanbeemployedinverifyingfacialmotorbranches,causingmusclespasms
whenanerveiscontacted.Thefacialtrunkislargeenoughforanastomosisofthecut
end,shouldthisbenecessary.Alargecutaneousnerveofthecalf(suralnerve)isoften
usedinthisproceduretografttothecontralateralintactnerve.Thesmallerbranchesare

injuredmoreoftenandaremuchlesseasilysutured.Norepairwillcompletelyrestore
function.Atractioninjurymayresultintemporaryparesisorpermanentinjury.
BrennerandSchoeller309reportedthatthemassetericnerve,abranchofthemandibular
nerve(Fig.1100),isapossibledonorforfacialnerveanastomosistorestorefunction
(closureofthemouthandeye)followingfacialnerveparalysis.Spira310was
perhapsthefirsttoanastomosethemassetericnervetothefacialnerve.Themasseter
muscleisdenervatedbutitsfunction,
accordingtoBrennerandSchoeller,309maybetakenoverbythetemporalmuscle.Other
nervesusedtorestorefacialnervefunctionarethehypoglossal,spinalaccessory,and
glossopharyngealnerves.
FIG.1100.
Page162of203
Diagramofthemandibularnerveintheregiondeeptotheramusofthemandible.In
thislateralviewtheoticganglion,situatedonthemedialsideofthemandibularnerve,is
indicatedinoutline.Thebranchofthemandibulartothetensorvelipalatini,which
passesmediallythroughtheoticganglion,isnotshown.(ModifiedfromHollinshead
WH.AnatomyforSurgeons(2nded):Vol.1,TheHeadandNeck.NewYork:Harper&
Row,1968;withpermission.)
Fournieretal.311reportedthatthemotordistributionofthemandibularnervemakesita
possibilityforamassetericfacialanastomosistorestorefacialfunction.Theywrote,
Themodestresultsandthesideeffectsofthefaciohypoglossalanastomosisusedfor
facialrehabilitationhaveledustoconsiderananastomosisbetweenamotorbranchofthe
trigeminalnerveandthefacialnerve.Dissectionhasallowedustodemonstratethatthe
massetericnerveoffersthecharacteristicsandtherelationshipswhichshouldmakesuch
ananastomosisfeasible.
InjurytotheauriculotemporalnervecanproduceFreyssyndrome,inwhichtheskin
anteriortotheearsweatsduringeating(gustatorysweating;consideredpreviously
underSurgeryoftheParotidGland).
SubmandibularGlandsEmbryogenesis
Thesubmandibularglandsappearatapproximatelytheendofthe6thweek.The
endodermandoralepitheliumintheflooroftheprimitiveoralcavityareresponsiblefor
thegenesisoftheseglands.Theyarelocatedlateraltotheprimitivetongue.Aciniare
formedaroundthe12thweek.AccordingtoSperber,312theglandsalsobeginsecreting
atthistime.Thesubmandibularductisformedlaterbytheclosureofalineargroove.
SurgicalAnatomy
Thesuperficialportionofthesubmandibularglandisabout4cmlong,lyinginthe
submandibulartrianglesuperficialtothemylohyoidmuscle.Atongueofglandulartissue
passesdeeptothemuscle,envelopingitsposteriorbordertoformthemuchsmallerdeep
portionofthegland(seeFig.118).
Importantrelationshipsofthesuperficialportionare:(1)theinferiorsurfaceisrelatedto
thefacialveinandthecervicofacialbranchesofthefacialnerve,includingthemarginal
mandibularandcervicalrami;(2)thelateralsurfaceisrelatedtothefacial
Page163of203

artery;and(3)themedialsurfaceisrelatedtotheglossopharyngeal,lingual,and
hypoglossalnerves.
Thedeepportionofthesubmandibularglandisrelatedtothelingualnerveand
submandibularganglionabove,andthe
hypoglossalnervebelow(seeFig.119).
Thesubmandibular(Whartons)ductemergesfromthemiddleofthedeepportionofthe
gland,crossesthesublingualspace,andopensintothemouthonthesideofthefrenulum
ofthetongue.Proximallyitliesbetweenthemylohyoidandhyoglossusmuscles;distally
itliesbetweenthegenioglossusmuscleandthesublingualgland.
Thelingualnerve,abranchofthemandibulardivisionofthetrigeminalnerve(V),hasa
specialrelationshiptotheduct.25Thenerveliesfirstaboveandthenlateraltotheduct,
crossingbelowandthenmedialtoit(seeFig.119).Thedangerofinjuringthenerve
whensectioningtheductisobvious.Thehypoglossalnervemustalsobeprotected
inferiortotheduct.
MarginalMandibularNerve
Inabout50percentofsubjects,themandibularbranchofthefacialnerve(marginal
mandibularnerve)liesbeneaththelowermarginofthemandible.Intheremainderitlies
belowthemandible,posteriortothecrossingofthefacialartery16(seeFig.1
15).ZiarahandAtkinson,313afterdissecting110facialhalves,alsoreportedthatinmore
thanhalfoftheirspecimensthemandibularbranchranbelowthemandibleanddistalto
thefacialvessels.
Itisimportanttonotethatthemandibularnerveismultipleinabout80percentof
individuals.17
SurgeryoftheSubmandibularGlands
Withmalignanttumors,totalexcisionismandatory.Occasionallythelingualand
hypoglossalnervesshouldbesacrificed.Withinflammatoryprocess,abscessformation,
orlithiasisaveryanatomicincisionisadvised.
AnatomicComplications
VascularInjury
Thevesselsmostfrequentlyinjuredduringexcisionofthesubmandibularglandsarethe
facial(externalmaxillary)arteryand
vein.Martin314suggestedthatthefacialarteryorveinbeexposed,sectioned,andligated
wellbelowtheedgeofthemandible.Thedistalstumpofthevesselisthendissected
upwardwithupwardtractionsothatthemarginalmandibularnerveiscarriedupwardby
theloopofthevessel.Thearteryandveincanbesuturedtotheundersideoftheskinflap.
Thisprocedurewillensureligationofthesevesselsbeforetheyaresectioned
inadvertently.
NerveInjury
MarginalMandibularNerve:Theprocedureoutlinedaboveforavoidanceofvascular
injurycompletelyprotectsthemandibularnervefromsubsequentinjury.
Ifthemandibularbranchofthefacialnerveisinjureditresultsinaflatteningofthelower
lipontheaffectedside.Ifanervestimulatorisusedtoidentifythenerve,the
anterosuperiorportionoftheplatysmamaycontract.Depressionofthecornerofthe

mouthmayalsobeobserved.DingmanandGrabb17discussedthisresponse.
HypoglossalNerve:SeeRadicalNeckDissectionfollowinginthischapter.Lingual
Nerve:SeeRadicalNeckDissection.
SublingualGlandsandOtherSalivaryGlands
Embryogenesis
Thesublingualglandsappeararoundthe8thweek.Theyoriginatefromseveralepithelial
budsofendodermaloriginwhichare
Page164of203
locatedattheparalingualsulcus.Thebudsformmultipleductsbycanalization.
SurgicalAnatomy
Thepairedsublingualgland(Figs.1101,1102)isanamygdaloid(almondshaped),flat
andnarrowgland,smallerthantheothermajorsalivaryglands(parotidand
submandibular).Thesublingualglandislocatedunderthemucosaeofthefloorofthe
mouth.Itsboundariesare:
Superior:mucosaoftheoralfloor
Inferior:mylohyoidmuscle
Anterior:sublingualglandoftheotherside
Posterior:deepprocess(anteriorprolongation)ofthesubmandibular(submaxillary)
gland;rarely,thismaybeaffixedtoasecondaryinflammatoryprocess
Medial:lingualnerve,submandibularduct,andgenioglossusmuscle
Lateral:medialsurfaceofthelowermandible
FIG.1101.
Page165of203
Superficialanddeepstructuresinthesublingualregion.(Rightandleftindicate
thesideofthedrawing.)A,SuperficialStructures.Themucosaisintactontheleft;onthe
right,theregionhasbeenclearedofthevesselsandnerves.B,DeepStructures.The
vesselsandnerveshavebeenremovedontheleft,andontherightthevesselsandnerves
areinsitu.
FIG.1102.
Page166of203
Lateralviewofthesublingualregion.Thebodyofthemandiblehasbeenremoved.
Thismucousglandhasmultipleducts:10to30,accordingtoORahilly,315and8to20,
accordingtoGraysAnatomy.54Theductsdraindirectlyintotheoralcavityonthe
sublingualfold,withsomeofthementeringthesubmandibularduct.
SurgeryoftheSublingualGlandsandOtherSalivaryGlands
Acalculusmayformwithinthesubstanceofthegland(sialolith).Thecalculuscanbe
removedthroughamucosalincision,ortheglandintotocanberemoved.Thedanger
zoneisthemedialboundarywherethesubmandibularductandlingualnervearelocated.
Anotherpathologicconditionistheformationofacystormucocele,thewellknown
ranula.Originationoftheranulaisusuallyinthesublingualglandsorminorsalivary
glands,althoughitcanappearinthesubmandibularduct.Removalofthecystorthe

Page167of203
cystplusthesublingualglandisadvisableifpartialremovaloftheroofisnot
successful.
Itisnotwithinthescopeofthisbooktopresentallthesalivaryglands,especiallytheso
calledminorsalivaryglands(lingual,labial,buccal,palatal,etc.).Thesearelocatedinthe
mucosaorsubmucosaoftheoralcavity.Theyareductlessorhaveminute,veryshort
ducts.
Sincemosttumorsdevelopinginsublingualandothersalivaryglandsaremalignant,en
blocresectionisadvised.Johnsetal.73characterizedsalivaryglandcarcinomasas
infrequentinanysinglesurgeonsexperience.
HistologyandPhysiologyoftheSalivaryGlands
Thehistologyoftheparotid,submandibular,andsublingualglandsisthesame.Eachof
theseglandsiscomposedofparenchymalelements(lobuleswhichformlobes)and
connectivetissue.
Thebasicanatomicandphysiologicunitisthesalivon,whichconsistsofacinarcells,
myoepithelialcellscoveringtheacinarcells,andaductthatprovidesthepathwayforthe
saliva.
Thehistochemistryandmorphologyofoncocyticandoncocytoidtumorsofthesalivary
glandwasstudiedbyJohnsetal.316andPaulinoandHuvos.317
BranchialRemnantsEmbryogenesis
Betweenthefourthandsixthweeksofgestation,theembryonicforegutchangesfroma
flattenedtubeintoacomplicatedseriesofstructures,someofwhichrepresentthe
primordiaoftherespiratoryapparatusofouraquaticvertebralancestors.Inmammals
thesestructuresbecomerearrangedandadaptedtonewfunctions,ortheydisappear,
leavingonlyoccasionalvestiges(Table116).
Table116.DerivativesofBranchialArchesandPouches
Branchial
Derivatives
Arch
PouchandCleft
AorticArch
CranialNerve
FleshyStructures
SkeletalStructures
AnomalousRemnants
I(maxillaryandmandibular)
1st(transitory)
V
Anteriortwothirdsoftongue
Dorsal:incus
Ventral:malleus,Meckelscartilage
I(hyomandibular)

Dorsal:auditorycanal,tympanicmembrane,middleear,eustachian
tube
Ventral:cervicoauralfistula
Dorsal:
Page168of203
II(hyoid)
2nd(transitory)
VII
stapes
Ventral:styloidprocess,stylohyoidligament,lesserhornofhyoidbone
II
Pharyngealandpalatinetonsils
Cysts,sinuses,andfistulas
III
3rd
IX
Posteriorthirdoftongue,lingualtonsil
Ventral:greaterhornofhyoidbone
III
Dorsal:inferiorparathyroids
Cysts,sinuses(rare)
Ventral:thymus
IV
4th(leftaorticarch;rightbrachiocephalic)
X
Epiglottis,baseoftongue
Ventral:thyroidcartilage
IV
Dorsal:superiorparathyroids
Cysts?
Ventral:thymus
V
5th(transitory)
X
(Rare)
Ventral:cricoid,arytenoidcartilages
Ultimobranchialbody(parafollicularcellsofthyroid)
Cysts?
VI
6th(proximalpulmonaryartery,distalductusarteriosus)
Trachealcartilage
Source:SkandalakisJE,GraySW,RoweJSJr.AnatomicalComplicationsin
General

Page169of203
Surgery.NewYork:McGrawHill,1983;withpermission.
Inothersectionsofthischapterwehavediscussedstructuresadaptedtonewfunctions:
thethyroidandparathyroidglandsandtheultimobranchialbodies.Hereweare
concernedwithstructuresthatnormallydisappearduringembryoniclife.Thesearethe
ectodermalcleftsandtheendodermalpouchesofthepharynx.
Ofthesegilllikeorgans,onlythedorsalportionofthefirstcleftandfirstpouchpersist
astheexternalauditorymeatusfromtheformerandthemiddleearandeustachiantube
fromthelatter.
SurgicalAnatomy
Fistulas
Fistulasarepatentductlikestructuresthathavebothexternalandinternalorifices.
Cervicoauricularfistulasextendfromtheskinattheangleofthejaw,andmayopeninto
theexternalauditorycanal.These
fistulaslieanteriortothefacialnerve.Theyareremnantsoftheventralportionofthe
firstbranchialcleft(Fig.1103).FIG.1103.
Congenitalcervicoauralfistulaorcyst.Thisisapersistentremnantoftheventralportion
ofthefirstbranchialcleft.Thetractmayormaynotopenintotheexternalauditorycanal.
(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.AnatomicalComplicationsin
GeneralSurgery.NewYork:McGrawHill,1983;withpermission.)
Lateralcervicalfistulasalmostalwaysarisefromtheventralportionofthesecond
branchialcleftandpouch.Theyoriginateonthelowerthirdoftheneckontheanterior
borderofthesternocleidomastoidmuscle.Theorificemaybepigmented.Thepathis
upwardthroughtheplatysmamuscleanddeepfascia.Abovethehyoidbonethetrack
turnsmediallytopassbeneaththestylohyoidandtheposteriorbellyofthedigastric
muscle,infrontofthehypoglossalnerve,andbetweentheexternaland
Page170of203
internalcarotidarteries.Itentersthepharynxontheanteriorsurfaceoftheupperhalf
oftheposteriorpillarofthefauces(Fig.1104A).Itmayopenintothesupratonsillar
fossaorevenintothetonsilitself.
FIG.1104.
Trackofasecondpouchandcleftfistulapassingfromthetonsillarfossaofthepalatine
(faucial)tonsilstotheneck.A,Completefistula.B,External(cervical)andinternal
(pharyngeal)sinuses.C,Cystofbranchialcleftoriginlyinginthecarotidnotch.
(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.AnatomicalComplicationsin
GeneralSurgery.NewYork:McGrawHill,1983;withpermission.)
Sinuses
Internalsinusesareblindlyendingspacesthatextendoutwardfromopeningsinthe
pharynx;externalsinusesareblindlyendingspacesthatextendinwardfromopeningsin
theskin.

Internalsinusesareusuallyasymptomaticand,hence,undetected.318Externalsinuses
usuallyariseattheanteriorborderofthesternocleidomastoidmuscleandendinacystic
dilatation.Manysuchsinusesresultfromaninfectedcystorprevious
Page171of203
incompleteexcisionofacyst(Fig.1104B).
Cysts
Cystsaresphericalorelongatedspaceslyinginthetrackofabranchialpouchorcleftand
havenocommunicationwiththepharynxorskin.
Superficialcystslieattheedgeofthesternocleidomastoidmuscle.Deepercystslieon
thejugularveinorinthebifurcationofthecarotidartery(Fig.1104C).Theseareof
branchialcleftoriginandarelinedwithstratifiedsquamousepithelium.Cystsonthe
pharyngealwalldeeptothecarotidarteriesareusuallyofbranchialcleftorigin.Theyare
linedwithciliatedepitheliumunless
inflammatoryorpressurechangeshaveoccurred(Fig.1105).SkandalakisandGray83
considertheseembryonicstructuresingreaterdetail.
FIG.1105.
Incompleteclosureofthesecondbranchialcleftofthepouchmayleavecysts:TypeI,
superficial,attheborderofthesternocleidomastoidmuscle.TypeII,betweenthemuscle
andthejugularvein.TypeIII,inthebifurcationofthecarotidartery.TypeIV,inthe
pharyngealwall.TypesI,II,andIIIareofsecondcleftorigin;TypeIVisfromthe
secondpouch.M,sternocleidomastoidmuscle;V,jugularvein;A,carotidartery.
(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.AnatomicalComplicationsin
GeneralSurgery.NewYork:McGrawHill,1983;withpermission.)
SurgeryoftheBranchialRemnants
Surgeryisthetreatmentofchoiceforallcysts,sinuses,andfistulasrelatedtothe
branchialremnants.
Branchialremnantsoriginatinginthepiriformrecesscancauserecurrentfistulasor
abscessesintheneck.Kimetal.319recommendchemocauterizationoftheinternal
openingtoavoidrecurrencefrominadequateremovalofthefistulatract.
Page172of203
AnatomicComplicationsVascularInjury
Theexternalandinternalcarotidarteriesjustabovethebifurcationofthecommon
carotidarteryareespeciallypronetoinjurywhileperformingexcisionofthebranchial
remnants,becauseasecondcleftcystorthepathofasecondcleftfistulawilllieinthe
crotchofthebifurcation.
Thefollowingveinsmustbeavoidedorligatedduringexcisionofthebranchial
remnants:theexternaljugular,anteriorjugular,commonfacial,lingual,andinternal
jugular.
NerveInjury
Afirstcleftsinusorcystpassesoverorunderthefacialnervebelowandanteriortothe
ear.Thecystmaydisplacethenerveeitherupwardordownward.Whenremovingthe
cyst,thesurgeonmustbecarefultoprotectthenerve.

Severalnerveswillbefoundabovethepathwayofasecondcleftorpouchbranchial
fistula:
Mandibularbranchofthefacialnerve(protectionofthisnervehasbeenconsidered
underSubmandibularGlands:AnatomicComplications)
Cervicalbranchofthefacialnerve(theskinshouldbeincised45cmbelowthe
mandibularangle)
Spinalaccessorynerve(maybeinjuredwhentryingtofreeacystorfistuloustractfrom
thesternocleidomastoidmuscle)
Descendenshypoglossi(superiorrootoftheansacervicalis)(maybecutifnecessary)
Hypoglossalnerve(thefistulacrossesthenerveabovethebifurcationofthecommon
carotidartery)
Superiorlaryngealnerves(seeAnatomicComplicationsofThyroidectomy:Nerve
Injuryfordiscussionofeffectsofinjury)Vagusnerve(liesparalleltothecarotidartery
[thefistulacrossesthenervenearthelevelofthecarotidbifurcation])
OrganInjury
Thepharyngealopeningofafistulaoraninternalsinusmustbeclosedwithoutproducing
alargeiatrogenicdefect.Rememberthatthisisatornearthetonsillarfossa.Uncontrolled
bleedingcanbeaproblem.
InadequateProcedures
Drainageoraspirationofbranchialcystsisuseless,andwillsoonerorlaterresultin
infection.Removalofallepithelialtissueistheonlycure.
RadicalNeckDissectionIntroduction
Aradicalneckdissectioninvolvescompleteexcisionoftheprimarylesion,togetherwith
allnonessentialstructuresandtheirlymphnodes,collectinglymphtrunks,fascia,andfat.
BydefinitionradicalneckdissectioninvolvesthelevelsoflymphnodesItoV,theSCM
muscle,cranialnerveXI,andtheinternaljugularvein.Thebedofaradicalneck
dissectionisboundedabovebytheinferiorborderofthemandible,belowbytheclavicle,
posteriorlybytheanteriorborderofthetrapeziusmuscle,andanteriorlybythemidline.
Inadditiontolymphatictissue,whichmustberemovedascompletelyaspossible,
nonlymphatictissuefallsintothreecategories:
Page173of203
(1)structuresthatcanbesacrificedwithimpunity;
(2)structureswhosesacrificeiscontroversial,especiallyforcosmeticreasons;and
(3)structuresthatmustbepreservedunlessdirectlyinvadedbycancer.Structuresin
thesecategoriesarelistedinTable117.Table117.SynopsisofRadicalNeck
Procedures
Structures
MaybeSacrificed
Controversial
MustbePreserveda
Organs
Submaxillarygland,lowerpoleofparotidgland
None

Thyroidgland,parathyroidglands
Muscles
Omohyoid,sternocleidomastoid
Platysma,digastric,stylohyoid
Allothermuscles
Vessels
Externaljugularvein,facialarteryandvein,superiorthyroidartery,lingualartery
Internaljugularvein
Externalcarotidartery,internalcarotidartery,subclavianarteryandvein,thoracic
duct
Nerves
AnteriorcutaneousC2C3,supraclavicularC3C4,ansahypoglossi,greatauricularnerve
Spinalaccessorynerve
Mandibularbranchoffacialnerve,superiorlaryngealnerve,recurrentlaryngealnerve,
facialnerve,lingualnerve,hypoglossalnerve,phrenicnerve,vagusnerve,cervical
sympatheticnerve,carotidsinusnerves,brachialplexus,nervestorhomboidandserratus
muscles
aUnlessinvadedbycancer.
Source:SkandalakisJE,GraySW,RoseJSJr.AnatomicalComplicationsinGeneral
Surgery.NewYork:McGrawHill,1983;withpermission.
Radicalneckdissectionmustbeplannedasacurativeprocedure.Becauseofthe
morbidityofsacrificeofcranialnerveXI,whennodesintheareaarenotenlargeda
modifiedneckdissectionisattempted.
TheBrazilianHeadandNeckCancerStudyGroup320presentedresultsofatrial
comparingmanagementoforalsquamouscarcinomausingmodifiedradicalclassical
neckdissectionandusingsupraomohyoidneckdissection.Thereportindicatedthatthe
recurrenceandsurvivalratesweresimilarwithbothprocedures.Supraomohyoidneck
dissectionwasrecommendedasstandardelectivetreatmentforT2T4oralsquamouscell
carcinomas.
SurgicalAnatomy
Fascia
SuperficialCervicalFascia
Page174of203
Thetransversecervicalnerve,greaterauricularnerve,lesseroccipitalnerve,and
supraclavicularnervesmustbesacrificed.Theresultisanesthesiaoftheposteriorscalp,
neck,andshoulder.321
Thereisdisagreementabouttheneedforsacrificingtheplatysmamuscle.Somewould
sacrificethemuscleroutinely.Othersbelievethatpreservationofthemuscleminimizes
scarringandthatoncesuperficiallymphaticsareinvolved,thecarcinomais
sowidelydisseminatedthatnothingisgainedbyfurthersurgicalprocedures.23
DeepCervicalFascia
Thedeepcervicalfasciamustberemovedascompletelyaspossible,becauselymph
nodesandlymphaticvesselsaredistributedprimarilyintheconnectivetissuebetweenthe

layersofthefascia.Thecarotidsheathandtheinternaljugularveinalsoshouldbe
sacrificed.
Thesternocleidomastoidmuscleisusedinreconstructionofradicalproceduresofthe
neck,thereforeknowledgeoftheblood
supplyofthemuscleperhapswillminimizetheriskofmusclenecrosis.Kierneretal.322
reportedthatthearterialbloodsupplyofthelowerthirdofthesternocleidomastoid
muscleisconstantlyprovidedbyabranchofthesuprascapularartery.
TrianglesAnteriorTriangle
Submentaltriangle:Removetheentirecontents.
Submandibulartriangle:Removethesubmandibularglandandlymphnodes.
Carotidtriangle:Removetheinternaljugularvein.Highligationoftheveinis
facilitatedbyremovalofthelowerpoleoftheparotidgland.Thegreatauricularnerve
andallsuperficialbranchesofthecervicalnervesshouldbecut.Alllymphnodesalong
theinternaljugularveinmustberemoved.ThefinalresultisshowninFigure1106.
FIG.1106.
Page175of203
Thecompletedradicaldissectionoftheneck.Remainingstructuresmayberemovedif
theyareinvolvedinmalignantgrowth.(ModifiedfromSkandalakisJE,GraySW,Rowe
JSJr.AnatomicalComplicationsinGeneralSurgery.NewYork:McGrawHill,1983;
withpermission.)
PosteriorTriangle
Removealltissueabovethespinalaccessorynervewithoutinjuringthenerve.Withblunt
dissection,freethenervefromtheunderlyingtissue.Ligatetheexternaljugularvein
closetothesubclavianvein,andtransectthesternocleidomastoidandomohyoidmuscles.
Theareabeneaththespinalaccessorynerveisthedangerzone23ofBeahrs.Itcontains
severalstructuresthatmustbeidentifiedandsavedifpossible:thenervestothe
rhomboidandserratusanteriormuscles,thebrachialplexus,thesubclavian
Page176of203
arteryandvein,andthephrenicnervewiththeanteriorscalenemusclebetween.The
objectofdissectioninthisareaistoremovecompletelythetransversecervical(inferior
horizontal)andspinalaccessorychainsoflymphnodes.
Thethoracicductontheleftandthelymphaticductontherightlieinamassofareolar
connectivetissue,deeptothesternocleidomastoidmuscleandposterolateraltothe
internaljugularvein.Somelymphatictrunksmayopenindependentlyintothesubclavian
orjugularveins.Theyshouldbepreservedifpossible,butiftheyhavebeeninjured,
ligatethem.
Betweentheinternaljugularveinandthecommoncarotidarteryliestheansacervicalis,
whichinnervatesthestrapmusclesoftheneck.Thisnerveisonorinthecarotidsheath
medialtotheinternaljugularvein.Itmaybecutwithimpunity.
Nerves
MarginalMandibularNerve

Themarginalmandibularnerveislocatedinahorizontal(transverse)orientation.Itis
foundjustaboveandsuperficialtothefacialarteryandvein,justundertheplatysma
muscleandabovethedeepcervicalfascia.
NOTE
Thecervicalbranchofthefacialnervecanbecutwithimpunitysinceitinnervatesonly
theplatysmamuscle.
Themarginalbranchinnervatesthemusclesofthelowerlip(quadratuslabiiinferioris
andmentalis).Thereforeitshouldbeprotectednotonlyforfunctionalreasonsbutalso
forcosmeticreasons,toavoidanabnormalfacialexpressionandahighlyasymmetrical
mouthcorner.
Anincisionintheskin45cmbelowthemandibularanglewillprotectthenerves.
LingualNerve
Thelingualnerve,hypoglossalnerve,andtheductofthesubmandibularglandtravel
togetherabove(deepto)themylohyoidmuscle.Thistriocanbeseenafterretractingthe
posteriorborderofthemylohyoidmuscle.Thelingualnerveisfirstseenatahigherlevel
thanthesubmandibularduct;anteriorly,however,itpassesdeeptotheducttoreachthe
tongue.Thehypoglossalnerve,themostinferiormemberofthetrio,passeshorizontally
forwardintheupperpartoftheneckandentersthefloorofthemouthbypassingdeepto
themylohyoidmuscle.Thereafter,thehypoglossalnervepassesintothesubstanceofthe
tongue,distributingbranchestoitsmusculature.
Thelingualnerveprovidesgeneralsensoryandtastefiberstothetongue;thehypoglossal
nerveprovidesmotorsupplytoallofthemusculatureofthetongueexceptthe
palatoglossus,whichissuppliedbythevagus.
HypoglossalNerve
Thehypoglossalnerveliesexternaltothehyoglossusmuscle,underanddeeptothe
submandibularglandonitswaytothetongue,beneaththeposteriorbellyofthedigastric
muscle.Thisnervehasseveralfellowtravelers,suchasthehypoglossalvenacomitantes
andthelingualartery.Thelingualarterypassesdeeptothehyoglossusmuscletoenter
thesubstanceofthe
tongue.Coursingbesidethehypoglossalnerve,thelingualarterymaybelocatedabove
orbelowthenerve.Beahrs23statedthatthehypoglossalnervemaybeinjuredinthis
location.Theresultisthatwhenprotruding,thetonguedeviatestotheparalyzedside.
Thisisduetoparalysisofalltheintrinsicandextrinsicmusclesofthetongue,excluding
thepalatoglossus.
Primaryrepairofthehypoglossalnervebymicrosurgicaltechniqueispossibleifthe
injuryisrecognizedduringsurgery.Whenthehypoglossalnerveisusedtoreplacethe
injuredfacialnerve,thepatientisadvisedtomovethetonguetotheinjuredside
whentryingtosmile.CarneyandAnderson323reportedhypoglossalnerveandinternal
carotidarteryentrapmentresultingfromaninflammatoryprocessofthesurrounding
lymphnodesintheareawherethenerveisveryclosetotheartery.
VagusNerve
Page177of203

Veryrarelythevagusnerveisdamagedduringradicalneckdissection.Eventhough
thenerveisposteriortothecommoncarotidarteryandinternaljugularveinandnot
readilyseen,thecarotidtriad,ofwhichthevagusisapart,iseasilyrecognized.However,
ifthevagusnerveisinvolvedwithtumor,itssacrificeisnecessary.
PhrenicNerve
Thephrenicnerveislocatedontheventralsurfaceoftheanteriorscalenemuscle,deepto
theprevertebralfascia.Crossingsuperficialtothenervearethelateralbranchesofthe
thyrocervicaltrunk;thatis,thetransversecervicalandsuprascapulararteries.Unilateral
paralysisofthehemidiaphragmafterdivisionofthephrenicnerveistoleratedwell.
SpinalAccessoryNerve
Thepathwayofthisnerveintheposteriortriangleisenigmaticandpeculiar.Gordonet
al.324notedthattheaccessorynerveisvulnerabletoinjurydespitecarefulpreservation
duringsurgicaldissection;itisquitevulnerableintheposteriortriangle.Other
workers325327alsoemphasizedthevulnerabilityofthenervetoinjury,andcitedthe
occurrenceofmuscleparalysiswithoutdiscerniblecause.OBrien328reviewedthe
indicationsformodifiedcervicaldissectionsandmethodsofsparingthespinal
accessory(andother)importantregionalnerves.
Thespinalaccessorynerveissaidtobelocatedbetweentwolayersoffasciaand
separatedfromthelevatorscapulaebyaheavydensefascia.Wehaveseenthis
occasionally.Wenoticedthenerveveryclosetotheskin(0.51.5cm)inthe
subcutaneoustissueoftheposteriortriangle.Thisisthereasonthatthenerveisso
vulnerableinthisarea.Itspositioncanbeapproximatedbyalinedrawnfromapoint
twothirdsofthedistanceuptheposteriorborderofthesternocleidomastoidandby
anotherpointonethirdofthedistanceuptheanteriorborderofthetrapezius.27The
nerveshouldbeprotected.329,330
Thedoublelayer(superficialanddeep)offasciainthisareaisalsopeculiar.Thedeep
layer(prevertebralfascia)isdense,butthesuperficiallayer(investinglayer)isverythin
andoccasionallyunnoticeable.Therefore,weadvisethattheknifenotbeusedafter
makingtheskinincision.Instead,usingahemostat,carefullyseparatethetissuesinthe
pathwayofthenervefromtheposteriorborderofthesternocleidomastoidmuscle,
movingobliquelytowardtheanteriorborderofthetrapeziusmusclewherethespinal
accessorynervedisappearsunderthetrapezius.
Wehaveseenthespinalaccessorynervebifurcateandtrifurcatepriortoits
disappearanceunderthetrapezius,orbifurcateandtrifurcateveryclosetotheposterior
borderofthesternocleidomastoidmuscle.Wehavealsoseenthenerveendatthe
posteriorborderofthesternocleidomastoidmuscle.Thespinalaccessoryreceives
contributionsfromthe2nd,3rd,and4thcervicalnerves.Presumablythesecontributions
aresensoryinfunction.However,becauseofcontributionsfromC3C5,somepatients
havetrapeziusfunctionevenwhencranialnerveXIissacrificed.Thelowercontributions
canoccurintheposteriortriangle.
Sooetal.331statedthattheexactmotorinnervationofthetrapeziusmuscleis
controversial.Thespinalaccessorynerveinnervatespracticallyallsegments(regions)of
themuscle.However,whenthespinalaccessoryendsintheSCMmuscle,theinnervation
ofthetrapeziusisviaC3.Inourexperience,thebranchfromthespinalaccessorytothe

trapeziusmaydivergefromtheSCM,joiningthebranchfromC3,thereafterdescending
tothetrapezius.
Brownetal.332recommendedchangingthenameofthespinalaccessorynervetothe
spinalaccessorynerveplexus,presumablyduetothecomplexityofitscontributionsand
branchingpatterns.Theynotedthatwithlossofthenerve,paralysis
ofthetrapeziusresulted,withdroopingandinternalrotationoftheshoulder.Zibordiet
al.333presentedaverygooddescriptionoftheresultsofinjurytotheaccessorynerve.
Threetofourlymphnodesareverycloselyassociatedwiththespinalnerveinthe
posteriortriangle.Withseverelymphadenitis,thenervemaybefixedwithonelymph
node,andaccidentallyseveredduringlymphnodeexcisionalbiopsyintheposterior
triangle.AccordingtoKingandMotta,334lymphnodebiopsywasthepredominant
reasonforinjurytotheaccessorynervein
Page178of203
37cases.Brownetal.332alsoobservedthattheaccessorynervewaseasilyremoved
alongwithalymphnodetowhichitwasdenselyadherent.DonnerandKline335noted
thatthespinalaccessorynervewasthenervemostcommonlyinjuredby
accident.
DeckerandDuPlessis336reportedthattheoccipitalarterycrossingthehypoglossalnerve
givesoffasternomastoidbranchwhichfollowsthespinalaccessorynerve.Theoccipital
arteryveryconsistentlycrossessuperiortothehypoglossalnervefromanteromedialto
posterolateral.Asitdoesso,itgivesoffthesternocleidomastoidartery.Thisartery
reachesthemuscleparallelwith,butinferiorto,thepointofentranceofthespinal
accessorynerveintotheSCM.Thus,thisvesselcanbehelpfulinlocatingthenerve.
AnatomicComplications
Thosewhoundertake[radicalneckdissection]shouldbeawareofthevitalimportanceof
anaccurateanatomicknowledgeofthefieldbeforeacceptingtheresponsibilityofthe
treatmentofapatientwithmetastaticdiseaseinvolvingtheneckarea.
SouthwickandSlaughter337VascularInjury
Kerthandassociates321statedthatthevesselsinjuredinaradicalneckdissectionare(in
orderoffrequency):theinternalandexternaljugularveins,subclavianvein,thoracic
duct,andcarotidartery.
InternalandExternalJugularVeins
Theinternaljugularveinshouldbeligatedasclosetothesubclavianveinaspossible.
Venousreturnwillthenbethroughthevertebral,pharyngeal,pterygoid,esophageal,deep
cervical,andoccipitalvenousplexuses.Themostimportantoftheseisthe
vertebralplexus.338
Unilateralligationofexternalandinternaljugularveinsproducestransientcyanosisand
edemaofthehead.Bilateralligationorexcisionmustbeundertakenwithcaution.
Martin314consideredsimultaneousbilateralligationstandardprocedureinselected
cases.However,fromtheworkofseveralauthors,Zarem339calculatedthatthereisa
20percentmortalityrateifligationofbothsidesisdonesimultaneously.Zaremwould
allowatleastonemonthbetweenligationstopermitthevertebralveinstocompensatefor
increasedvenousflow.

Toomuchtractionontheinternaljugularveincanresultinatearatitslowerend.The
veinwillthenretractundertheclavicle,requiringthemidportionofthebonetobe
removedinordertoreachandligatethevein.
SubclavianVein
Severalauthors321,337,339havewarnedofthedangerofairembolismthroughthe
internalorexternaljugularveinsorthesubclavianvein.Thesubclavianveinisthedirect
continuationoftheaxillaryvein.Itisrelatedtothefirstribandreceivestheexternal
jugularveinattheareaoppositethemiddleoftheclavicle.Immediatesuturingofthe
veinsismandatory.Theactualmortalityratefromairembolismisnotknown.
Pneumothoraxandpneumomediastinumalsohavebeenreported.
ThoracicDuct
Postoperativecervicalchylefistulamaycomplicateneckdissection.Nussenbaumet
al.340recommendearlyoperativeinterventionifthepeak24hourdrainageisgreater
than1000mLwithoutapromptresponsetomedicalmanagement.Theyadvisethat
persistentlowoutputdrainageafter10daysisassociatedwithaprolongedmanagement
courseandtreatment
relatedcomplications.Gregor341advocatestotalparenteralnutritiontocontrolfluidand
proteinlosswhileavoidingflowofchyle.Ifthefistuladoesnotresolve,fibringluewith
meshandmuscleflapsisusuallysuccessfulinachievingclosure.
Page179of203
Informationaboutcomplicationsofinjurytothethoracicductwillbefoundinthe
chapteronthelymphatics.
CarotidArtery
Manyindividualswilltolerateunilateralobstructionofthecarotidartery,butthis
tolerancecannotalwaysbedeterminedpriorto
operation.Completeunilateralobstructionoftheinternalcarotidarterycarriesagreat
chanceofmortality.Mooreetal.342statedthat23%ofpatientswhounderwentelective
carotidarteryligationsufferedstrokesand17%died.Ofthepatientsundergoing
compulsoryligation,50%sufferedstrokesand38%died.Twopatientsoutof4with
bilateralcarotidarteryligationssurvivedwithoutcomplications.TheaxiombyMooreet
al.isworthreprintinghere:
...everyeffortshouldbemadetopreservetheintegrityofthisvessel[carotidartery],and,
ifitsruptureisdeemedinevitable,electiveligationispreferabletoligationafter
exsanguinatinghemorrhage.
Schmeideketal.343reportedthatallpatientswithunilateralinternalcarotidartery
occlusionhadrecurringepisodesoffocalcerebralischemia.Thepostoperativecourseof
superficialtemporalarterymiddlecerebralarteryanastomosiswasuneventfulin23
patients(82%).
Puttinietal.344reportedoperativemorbidityandmortalityof4.1%incasesofclinical
carotidstenosiswithcontralateralstenosis.
SouthwickandSlaughter337mentionedacaseinwhichthecommoncarotidarteryand
thevagusnervewereaccidentallyincludedinaligationoftheinternaljugularvein.

Pressurefrommanipulationofthecarotidsinusatthebifurcationofthecarotidarterycan
resultinserioushypotension.Ifsuchpressurecannotbeavoided,infiltrationofthearea
withXylocaineissuggested.339
NerveInjury
SpinalAccessoryNerve
Sectionofthespinalaccessorynerve(XI)denervatesthetrapeziusmuscle,limiting
abductionofthearmandelevationoftheshoulder.Subsequentwastingofthemuscle
resultsinadroppedshoulder.Theremaybewingingofthesuperiorangleofthe
scapula.Ifremovalofthenerveisconsideredunnecessary,itmustbeprotectedfrom
injury.Gordonandcolleagues324reported17casesofoperationsontheposterior
triangleinwhichnerveinjuryoccurredinspiteofcaretakentopreventit.
Ifinjuryisrecognizedintheoperatingroom,endtoendmicrosurgicalanastomosisisthe
procedureofchoice;greaterauricularnervegraftisoftenused.Iftheinjuryisrecognized
postoperatively,thenrepairshouldbedoneassoonaspossible.Repairafterthe3rdor
4thmonthfollowinginjurywillnotbesuccessful.Thesuralnervecanbeusedasagraft
ifanendtoendanastomosis
isnotpossible.IncommentstoDonnerandKline,HansPeterRichter345agreedwith
GabelandNunley346thattheresultsof
nerverepairarefarworseifrepairisdelayedmorethan4monthsaftertheinitialinjury.
Tindall,347inthesamecomments,furtherobservedthatthenervewasverysuperficial,
merely11.5cmfromthesurfaceoftheskin,andtherebyinjuredreadily.Shestatedthat
ifitcouldberepairedearly,anexcellentprognosiscouldbeanticipated.
ExternalLaryngealandRecurrentLaryngealNerves
Occasionally,thesenervesmaybeinjuredinradicalneckdissection.Injuryofthe
externallaryngealnerveproducesinabilitytotensethecord.Injuryoftherecurrent
laryngealresultsinaparamedianpositionofthecord,withairwayproblems.
RamusMandibularisoftheFacialNerve
Theramusmandibularisofthefacialnerveneednotbeinjuredifitisidentifiedand
protected.Topreservethenerve,placetheincision45cmbelowtheangleofthe
mandible(thisalsoprotectsthecervicalbranch).Rememberingthatthenerveisalways
abovethefacialvesselswillassistinidentification.
Page180of203
Otherbranchesofthefacialnerve,andthefacialnervetrunkitselfshouldbeavoided
unlesstheirsectionisnecessaryforatumoroftheparotidgland.
WequotefromSaffoldetal.348:
[S]electiveneckdissectionperformedinamannerpreservingthecervicalrootbranches
hasasmall,predictableimpactonsensationofthefaceandneck.Theupperanteriorneck
betweeneachfacialnotchofthemandibleistheregiontypicallyrenderedanesthetic.
Sacrificeofthecervicalrootbranchesresultsinasignificantextensivesensorydeficit
involvingtheentireipsilateralneck.
Brownetal.349suggestedthattheunpredictablepostoperativepainanddysfunctionthat
mayfollowradicalnecksurgeryislikelysecondarytotheviolationofthebloodsupply

ofcranialnervesIX,X,XIandXII,andstressedtheimportanceofsparingasmany
nervesandvesselsaspossible.
BrachialPlexus
Theuppercordofthebrachialplexusismostfrequentlyinjuredwhentheconnective
tissueoftheretroclavicularspaceisremoved.337
Remembertopreservethefollowingentities:
MarginalmandibularbranchofthefacialnerveLingualnerve
Hypoglossalnerve
Vagusnerve
Phrenicnerve
Spinalaccessorynerve
However,ifthereisfixationwithtumor,theabovestructuresshouldbesacrificed.Organ
Injury
Thethoracicductcanbesafelyligatedifitisinjured.Somesurgeons339suggestroutine
ligation.Thenumberoflymphatictrunksandtheirinconstantanatomymakesitdifficult
toavoidlymphaticleakage.
NeckDeformity
DucicandHilger350adviseunilateraldeepplaneneckdissectiontoachievebetter
symmetryandlessenneckdeformityfollowingradicalneckdissection.
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Thedevelopmentoftheneck.A,Fifthweek.Prominentbranchialarchesmarkthesiteof
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headandthorax.C,Twelfthweek.Fromthisstageon,thetrueneckispresent.(Modified
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Drawingsillustratingthehumanbranchialapparatus.A,Dorsalviewofthecranialpartof
anearlyembryo.BtoD,Lateralviews,showinglaterdevelopmentofthebranchial
arches.EtoG,Facialviews,illustratingtherelationshipofthefirstarchtothe
stomodeumorprimitivemouth.H,Transversesectionthroughthecranialregionofan
embryo,illustratingthebranchialarchcomponentsandtheflooroftheprimitivepharynx.
I,Horizontalsectionthroughthecranialregionofanembryo,illustratingthebranchial

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Branchialgrooves,branchialarches,pharyngealpouches,andclosingplates.(Modified
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Thethirdcervicalvertebraisatthelevelofthehyoidbone;thefourthandfifthcervical
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Anatomy.NewYork:McGrawHill,1963;withpermission.)
Sixthcervicalvertebra.(ModifiedfromBrantiganOC.ClinicalAnatomy.NewYork:
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Seventhcervicalvertebra.(ModifiedfromBrantiganOC.ClinicalAnatomy.NewYork:
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Properplacementofincisionsintheneckparallelingthenormallinesandcreasesofthe
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partialmobilizationhereandlowersegmentatB1.B,Excisionofcarotidtumoror
branchialcleftcyst.C,Diverticulumofesophagus.D,Scalenotomyorphrenicnerve
interruption.E,Drainageofsubmentalabscess.F,Excisionofthyroglossalcystorsinus.
G,Cricothyreotomy.H,Tracheotomy.I,Thyroidectomy.J,Drainageofcervicalabscess
atangleofjaw.K,Exposureofinternalorexternalcarotidarteries.L,Exposureof
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(ModifiedfromAnsonBJ,McVayCB.SurgicalAnatomy(5thed).Philadelphia,
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Selectedincisionsusedforclassicradicalneckdissection.A,Attie.B,EckersandByer.
C,MacFee.D,Morestin.E,Conley.F,LatyshevskyandFreund.G,Martin.H,Z.I,
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Definitivecarephase:neckinjuries.InGreenfieldLJ(ed).Surgery:ScientificPrinciples
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Algorithmforevaluationofpenetratingneckinjuries.(FromDemetriadesD,Theodorou
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Penetratingneckinjuriesmanagementguideline.GSW,gunshotwound;SW,stab
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Alternativesurgeryintraumamanagement.ArchSurg1998,133:11771181;with
permission.)
Theanteriortriangleoftheneckisdividedintofoursmallertrianglesbythedigastricand
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GraySW,RoweJSJr.Surgicalanatomyofthesubmandibulartriangle.AmSurg
1979;45:590596;withpermission.)
Schematicdrawingofananatomicanomaly.1,anteriorbellyofdigastricmuscle;2,
posteriorbellyofdigastricmuscle;3,accessorybelly;4,fibrousband.(Modifiedfrom
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Thefirstsurgicalplaneofthesubmandibulartriangle.Theplatysmaliesoverthe
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Theneuralhammocksformedbythemandibularbranch(upper)andtheanteriorramus
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givenincentimeters.Percentagesindicatethefrequencyoftheconfigurationin80
dissectionsofthesenerves.(FromSkandalakisJE,GraySW,RoweJSJr.Surgical
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Thethirdsurgicalplaneofthesubmandibulartriangle.Thesuperficialportionofthe
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muscle.(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.Surgicalanatomyofthe
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Thefourthsurgicalplaneofthesubmandibulartriangle.Thedeepportionofthegland
andductareexposed.(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.Surgical
anatomyofthesubmandibulartriangle.AmSurg1979;45:590596;withpermission.)
Theposteriortriangleoftheneck.Thetrianglemaybedividedintotwosmallertriangles
bytheomohyoidmuscle.(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.
AnatomicalComplicationsinGeneralSurgery.NewYork:McGrawHill,1983;with
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Theflooroftheposteriortriangle.
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Diagramofthecarotidsinus,carotidbody,andtheirinnervation.Whatpartthecarotid
branchofthevagusplaysinthisinnervationisnotknown.Notethatthecarotidbodylies
notsomuchin,asmedialto,thecarotidbifurcation.

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Variationsseeninrelationsbetweenscalenemusclesandthebrachialplexus.A,
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Thesuperficialfasciaoftheneckliesbetweentheskinandtheinvestinglayerofthedeep
cervicalfascia.CT,connectivetissue.(ModifiedfromSkandalakisJE,GraySW,Rowe
JSJr.AnatomicalComplicationsinGeneralSurgery.NewYork:McGrawHill,1983;
withpermission.)
Fasciallayersandspacesabovethehyoidbone,inasagittalsection.Notethatthe
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bone,inlongitudinalsection.(A,FromColbornGL,SkandalakisJE.ClinicalGross
Anatomy:AGuideforDissection,Study,andReview.PearlRiverNY:Parthenon,1993;
B,modifiedfromHollinshead,AnatomyforSurgeons,Vol1:TheHeadandNeck,New
York:Harper&Row,1968;withpermission.)
Theanchorofthethyroidgland:theligamentofBerry.Twoviewsofthevisceral
compartmentoftheneck.
Partofadiagrammaticsemifrontalsection,slantedsomewhatanteriorlyfrombehindthe
ramusofthemandible,toshowtherelationsofthesuperficiallayeroffasciatothe
parotidgland.
Chronicandacuteretropharyngealabscesses.
Diagrammaticrepresentationofbothcommoncarotidarteries(posteriorview).(Modified
fromMontgomeryRL.HeadandNeckAnatomy:WithClinicalCorrelations.NewYork:
McGrawHill,1981;withpermission.)
Commoncarotidarteryandinternalandexternalcarotidarteries.(Modifiedfrom
MontgomeryRL.HeadandNeckAnatomy:WithClinicalCorrelations.NewYork:
McGrawHill,1981;withpermission.)
Schemaoftheembryology,anatomy,andphysiologyofthecarotidbodyandcarotid
sinus,andthepathologyofthecarotidbody.(ModifiedfromSinghabhandhuB,Gray
SW,BryantMF,SkandalakisJE.Carotidbodytumors.AmSurg1973;39:501508;with
permission.)

Someofthecollateralchannelsavailableafterligationofthecommoncarotidartery.On
therightsideofthebodyareshownthechiefcommunicationsbetweenthetwosides;on
theleft,thechieflongitudinalanastomoses.
Internalandexternalcarotidarteries.(ModifiedfromMontgomeryRL.HeadandNeck
Anatomy:WithClinicalCorrelations.NewYork:McGrawHill,1981;withpermission.)
Ligationguidelines.
Page197of203
Internaljugularvein.(ModifiedfromMontgomeryRL.HeadandNeckAnatomy:
WithClinicalCorrelations.NewYork:McGrawHill,1981;withpermission.)
ThelymphnodesoftheneckfromHealeysclassification.SH,Superiorhorizontalchain.
IH,Inferiorhorizontalchain.PV,Posteriorverticalchain.IV,Intermediateverticalchain.
AV,Anteriorverticalchain.(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.
AnatomicalComplicationsinGeneralSurgery.NewYork:McGrawHill,1983;with
permission.)
Somedrainagetolymphnodesoftheintermediatevertical(jugular)chain.(Modified
fromSkandalakisJE,GraySW,RoweJSJr.AnatomicalComplicationsinGeneral
Surgery.NewYork:McGrawHill,1983;withpermission.)
ThelymphoidstructuresofthetonsillarringofWaldeyersurroundingthepharynx.
(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.AnatomicalComplicationsin
GeneralSurgery.NewYork:McGrawHill,1983;withpermission.)
Thethoracicductandmainleftlymphatictrunks.Trunksarevariableandmayenterthe
veinswiththethoracicductorseparately.(ModifiedfromSkandalakisJE,GraySW,
RoweJSJr.AnatomicalComplicationsinGeneralSurgery.NewYork:McGrawHill,
1983;withpermission.)
Therightlymphaticductisformedbythejunctionofseverallymphatictrunks.Ifthey
entertheveinsseparately,theremaybenorightlymphaticduct.(Modifiedfrom
SkandalakisJE,GraySW,RoweJSJr.AnatomicalComplicationsinGeneralSurgery.
NewYork:McGrawHill,1983;withpermission.)
Thecervicalsympathetictrunk.(ModifiedfromDeckerGAG,DuPlessisDJ(eds).Lee
McGregorsSynopsisofSurgicalAnatomy(12thed).Bristol,England:JohnWright,
1986;withpermission.)
Superficialanddeepcervicalplexuses.(ModifiedfromHealeyJEJr,HodgeJ.Surgical
Anatomy.Philadelphia:BCDecker,1990;withpermission.)
Superficialgroupofthecervicalplexus.(ModifiedfromHealeyJEJr,HodgeJ.Surgical
Anatomy.Philadelphia:BCDecker,1990;withpermission.)
Deepgroupofthecervicalplexus.(ModifiedfromHealeyJEJr,HodgeJ.Surgical
Anatomy.Philadelphia:BCDecker,1990;withpermission.)
Schemaofthebrachialplexus.
Schemaoftheformationofthebrachialplexus,anditsbranchesintheneck.Thetwigsto
thelongusandscalenemusclesarenotshown.
ThedottedcircleisErbspoint.Meetingarethefollowingnerves:AandB,thefifthand
sixthrootsofthebrachialplexusgoingtoformC,theuppertrunkofthebrachialplexus;

DandE,anteriorandposteriordivisionsoftheuppertrunk;F,suprascapularnerve;G,
nervetosubclaviusmuscle.
Normalvestigesofthyroidglanddevelopment.Noneareofclinicalsignificance,buttheir
presencemaybeofconcerntothesurgeon.(ModifiedfromSkandalakisJE,GraySW,
RoweJSJr.AnatomicalComplicationsinGeneralSurgery.NewYork:McGrawHill,
1983;withpermission.)
Theembryonicpathofdescentofthethyroidgland.Anectopicthyroidmayremainatits
leveloforigininthetongue,oritsdescentmaybeinterruptedatanypointalongthe
pathway.Hyperdescentintothethorax(primarilyretrosternalthyroid)isalsopossible.
(ModifiedfromGraySW,SkandalakisJE,AkinJTJr.Embryologicalconsiderationsof
thyroidsurgery:Developmentalanatomyofthethyroid,parathyroid,andtherecurrent
laryngealnerve.AmSurg1976;42:621628;withpermission.)
Leftsideofdrawingillustratespossiblesitesofaccessoryectopicthyroidtissue.Right
sideofillustrationlistsotheranatomicentitiesfromwhichtissuemaybefoundwithinthe
thyroid.(ModifiedfromSkandalakisJE,GraySW.EmbryologyforSurgeons(2nded).
Baltimore:Williams&Wilkins,1994;withpermission.)
Page198of203
Thearterialsupplytothethyroidgland.Thethyroidimaarteryisonlyoccasionally
present.(ModifiedfromTzinasS,DrouliasC,HarlaftisN,AkinJTJr,GraySW,
SkandalakisJE.Vascularpatternsofthethyroidgland.AmSurg1976;42:639644;with
permission.)
Branchesofthesuperiorthyroidartery.(ModifiedfromMontgomeryRL.HeadandNeck
Anatomy:WithClinicalCorrelations.NewYork:McGrawHill,1981;withpermission.)
Relationsatthecrossingoftherecurrentlaryngealnerveandtheinferiorthyroidartery.
AC,Commonvariations.TheirfrequenciesaregiveninTable19.D,Anonrecurrent
nerveisnotrelatedtotheinferiorthyroidartery.E,Thenerveloopsbeneaththeartery.
(ModifiedfromTzinasS,DrouliasC,HarlaftisN,AkinJTJr,GraySW,SkandalakisJE.
Vascularpatternsofthethyroidgland.AmSurg1976;42:639644;withpermission.)
Thevenousdrainageofthethyroidgland.Theinferiorthyroidveinsarequitevariable.
(ModifiedfromTzinasS,DrouliasC,HarlaftisN,AkinJTJr,GraySW,SkandalakisJE.
Vascularpatternsofthethyroidgland.AmSurg1976;42:639644;withpermission.)
Threeconceptsofthelymphaticdrainageofthethyroidgland.A,Edisetal.352B,
McGregorandDuPlessis.76C,Hollinshead.36Allthreeconceptsarecorrectandbased
onthesamefacts.(ModifiedfromTzinasS,DrouliasC,HarlaftisN,
AkinJTJr,GraySW,SkandalakisJE.Vascularpatternsofthethyroidgland.AmSurg
1976;42:639644;withpermission.)
Thelymphnodesreceivingdrainagefromthethyroidgland.Afterthedescriptionof
Rouviere.359(ModifiedfromTzinasS,DrouliasC,HarlaftisN,AkinJTJr,GraySW,
SkandalakisJE.Vascularpatternsofthethyroidgland.AmSurg1976;42:639644;with
permission.)
Lymphnoderegionsofimportanceformanagementofthyroidcarcinoma.(Modified
fromCallenderDL,ShermanSI,GagelRF,BurgessMA,GoepfertH.Cancerofthe

thyroid.In:MyersEN,SuenJY(eds).CanceroftheHeadandNeck(3rded).
Philadelphia:WBSaunders,1996,p.485515;withpermission.)
Diagramillustratinglymphnodegroupsathighestriskforregionalmetastasisfrom
differentiatedthyroidcarcinoma.(ModifiedfromGoepfertH,CallenderDL.
Differentiatedthyroidcancerpapillaryandfollicularcarcinoma.AmJOtolaryngol
1994;15:167179;withpermission.)
Theembryonicaorticarchesandtherecurrenceofthelaryngealnerve.A,Normal
embryowiththird,fourth,andsixthaorticarchespresent.Thelaryngealnervearisesfrom
thevagusnerveandpassesunderandbehindthesixthaorticarch.B,Normaladult.On
theright,thelaryngealnervepassesunderthesubclavianartery;ontheleft,itpasses
undertheligamentumarteriosum.C,Inthepresenceofaretroesophagealright
subclavianartery,thenervepassestothelarynxwithoutrecurring.D,Inthepresence
ofarightaorticarch,therightnerveloopsunderthearch;theleftnervepassesdirectlyto
thelarynx.CandDareencounteredinlessthan1percentofspecimens.(Modifiedfrom
SkandalakisJE,DrouliasC,HarlaftisN,TzinasS,GraySW,AkinJTJr.Recurrent
laryngealnerves.AmSurg1976;42:629634;withpermission.)
Thecourseoftherecurrentlaryngealnerveatthethyroidglandin102cadavers.About
halfthenerveswerefoundinthegroovebetweenthetracheaandtheesophagus.A,
Lateralview.B,Crosssectionalview.(ModifiedfromSkandalakisJE,DrouliasC,
HarlaftisN,TzinasS,GraySW,AkinJTJr.Recurrentlaryngealnerves.AmSurg
1976;42:629634;withpermission.)
Zuckerkandlstuberculumsize.0,unrecognizable;1,onlyathickeningofthelateraledge
ofthethyroidlobe;2,smallerthan1cm;3,largerthan1cm.(ModifiedfromPelizzo
MR,ToniatoA,GemoG.Zuckerkandlstuberculum:anarrowpointingtotherecurrent
laryngealnerve(constantanatomicallandmark).JAmCollSurg1998;187:333336,
1998;withpermission.)
TheregionofthetubercleofZuckerkandl(themostposteriorextentofthethyroidlobe)
andthedistalcourseoftherecurrentlaryngealnerve(RLN).TherelationoftheRLNto
theremainingremnantofthyroidandmechanismforpossibleRLNinjuryareshown.
(ModifiedfromThompsonNW.Thyroidgland.In:GreenfieldLJ(ed).Surgery:
ScientificPrinciplesandPractice(2nded).Philadelphia:LippincottRaven,1997,pp.
12831308;withpermission.)
Page199of203
Branchingofthesuperiorlaryngealnerveandthecarotidarteries.A,Theinternal
branchcrossestheexternalcarotidarteryabovetheoriginofthelingualartery.B,The
internalbranchcrossesbelowtheoriginofthelingualartery.C,Thenervedividesmedial
totheexternalcarotidartery.(ModifiedfromDrouliasC,TzinasS,HarlaftisN,AkinJT
Jr,GraySW,SkandalakisJE.Thesuperiorlaryngealnerve.AmSurg1976;42:635638;
withpermission.)
Thesketchofthecoronalsectionofthelarynxshowsthesuperiorlaryngealnerve
trunk(s)intheenvironmentofthesternothyroidlaryngealtriangle,whichisbounded
laterallybythesternothyroidmuscle,mediallybytheinferiorpharyngealconstrictorand
cricothyroidmuscles,andinferiorlybythesuperiorpoleofthethyroidgland.a,single

nervetrunk,89sides(74.2%);b,singlenervetrunk,1side(0.8%);c,doublenerve
trunks,24sides(20%);d,doublenervetrunks,4sides(3.3%);e,triplenervetrunks,1
side(0.8%);f,quadruplenervetrunks,1side(0.8%).(ModifiedfromSunSQ,DongJP.
Anappliedanatomicalstudyofthesuperiorlaryngealnerveloop.SurgRadiolAnat
1997;19:169173;withpermission.)
Variationsoflaryngealnerves.TypeI,Vshapedin94sides(78.33.8%).TypeII,U
shapedin8sides(6.72.3%).TypeIII,Mixedin14sides(11.72.9%).TypeIV,
Juxtaposeddoublein1side(0.80.8%).TypeV,Juxtaposedtriplein1side(0.8
0.8%).SLN,superiorlaryngealnerve;ILN,internallaryngealnerve;SCG,superior
cervicalganglion;CT,communicatingtwig;ELN,externalbranchoflaryngealnerve;
CTB,cricothyroidmusclebranch;GB,thyroidbranch.(ModifiedfromSunSQ,DongJP.
Anappliedanatomicalstudyofthesuperiorlaryngealnerveloop.SurgRadiolAnat
1997;19:169173;withpermission.)
Relationshipbetweenthe(A)internaland(B)externalbranchesofthesuperiorlaryngeal
nervewiththesuperiorthyroidarteryandtheupperpoleofthethyroidgland.(Modified
fromDrouliasC,TzinasS,HarlaftisN,AkinJTJr,GraySW,SkandalakisJE.The
superiorlaryngealnerve.AmSurg1976;42:635638;withpermission.)
Classificationoftheexternalbranchofthesuperiorlaryngealnerve,accordingtothe
potentialriskofiatrogeniclesionduringahypotheticalthyroidectomy.Type1,Thenerve
crossesthesuperiorthyroidvessels1ormorecentimetersaboveahorizontalplane
passingtheupperborderofthesuperiorthyroidpole.Type2a,Nervecrossingthevessels
lessthan1cmabovetheplane.Type2b,Nervecrossingthevesselbelowtheplane.
(ModifiedfromCerneaCR,NishioS,HojaijFC.Identificationoftheexternalbranchof
thesuperiorlaryngealnerve(EBSLN)inlargegoiters.AmJOtolaryngol1995;16:307;
withpermission.)
Thesynthesisandsecretionofthyroxine(T4)andtriiodothyronine(T3).TSH,thyroid
stimulatinghormone;MIT,
monoiodotyrosine;DIT,diiodotyrosine.(FromPolkHCJr,GardnerB,StoneHH.Basic
Surgery(5thed).St.Louis:QualityMedical,1995;withpermission.)
Thephysiologicregulationofthyroidhormonesecretionandthethyroidtestswhich
measuretheseparameters.TRH,thyrotropinreleasinghormone;TSH,thyroid
stimulatinghormone;TSI,thyroidstimulatingimmunoglobulins;LATS,longacting
thyroidstimulator;TBG,thyroxinebindingglobulin;FTI,freethyroxineindex.
(ModifiedfromPolkHCJr,GardnerB,StoneHH.BasicSurgery(5thed).St.Louis:
QualityMedical,1995;withpermission.)
Managementflowchartforpatientwithsolitarythyroidnodule.TSH,thyroidstimulating
hormone;FNA,fineneedleaspiration;RAD,radiationabsorbeddose.(Modifiedfrom
JohnsME.Thesolitarythyroidnodule.CurrTherOtolaryngol1987;3:226229;with
permission.)
Thesuperiorthyroidvesselsshouldbeclampedanddividedwithinthesubstanceofthe
upperpoleofthethyroidgland.Failuretosecurethesevesselsadequatelywillresultin
massivehemorrhage.(ModifiedfromAkinJTJr,SkandalakisJE.Techniqueoftotal
thyroidlobectomy.AmSurg1976;42:648656;withpermission.)
Nervesandarteriesofthelarynx,lateralview.

Anenlarged,retrosternalthyroidglandshowingitsrelationtothepleura(dottedline).
(ModifiedfromHarlaftisN,TzinasS,DrouliasC,AkinJTJr,GraySW,SkandalakisJE.
Rarecomplicationsofthyroidsurgery.AmSurg1976;42:645647;withpermission.)
Dissectionoftherightsideofthehumanneck.Thelargevagalartery(A)receives
reinforcingbranches(R)fromthecommon(B)
Page200of203
andinternal(I)carotidarteries.Inadvertentdamagetothesevesselsincarotid
endarterectomymayaccountforinjurytothevagusnerve(N)andsubsequentvagal
palsy.(ModifiedfromFernandoDA,LordRSA.Thebloodsupplyofthevagusnervein
thehuman:itsimplicationincarotidendarterectomy,thyroidectomyandcarotidarch
aneurectomy.AnnAnat1994;176:333;withpermission.)
Neckdissectionofthehuman.Alargevagalvein(V)drainsvenousbloodtothesuperior
(S)andinferior(I)thyroidveins.Interruptiontothesevesselsinthyroidectomymay
accountforvagaldamageleadingtovoicechanges.ThevagusnerveisindicatedbyN.
(ModifiedfromFernandoDA,LordRSA.Thebloodsupplyofthevagusnerveinthe
human:itsimplicationincarotidendarterectomy,thyroidectomyandcarotidarch
aneurectomy.AnnAnat1994;176:333;withpermission.)
Neckdissectionofthehuman.Theprominentvagalvein(V)drainsintotheinferior
thyroidvein.Thevagalarteryarisingfromtheinferiorthyroidarteryliesalongsidethe
vein.Suturesplaceddistaltothepointofopeningofthevagalveinorthecommencement
ofthevagalarterymayresultindegenerativechangesoredemaofthevaguswith
consequentvagalpalsy.ThevagusnerveisindicatedbyN.(FromFernandoDA,Lord
RSA.Thebloodsupplyofthevagusnerveinthehuman:itsimplicationincarotid
endarterectomy,thyroidectomyandcarotidarchaneurectomy.AnnAnat1994;176:333;
withpermission.)
Dissectionoftheleftsideoftheneckandthorax.Thelargevagalartery(A)arisesfrom
theinferiorthyroidartery.Thisvesselbifurcatesintoascendinganddescendingbranches.
Thedescendingbranchreceivesreinforcingtwigsfromtheaorta,bronchial,and
esophagealarteries.Damagetothesesmallvesselsinthyroidectomiesandremovalof
aneurysmsoftheaorticarchmayalsocontributetovagaldamageandconsequent
symptomsofvagalpalsyandvoicechanges.ThevagusnerveisindicatedbyN;common
carotidarterybyB.(ModifiedfromFernandoDA,LordRSA.Thebloodsupplyofthe
vagusnerveinthehuman:itsimplicationincarotidendarterectomy,thyroidectomyand
carotidarchaneurectomy.AnnAnat1994;176:333;withpermission.)
Aplanoftherighthypoglossalnerveandansacervicalis.
Theansacervicalis,itsroots,anditsbranchestotheinfrahyoidmuscles.
Themigratorypathwaysoftheparathyroidglands.Theglandsmaybefoundatanypoint
alongthosepathways,usuallyatthelevelsindicatedbythehorizontalarrows.(Modified
fromGraySW,SkandalakisJE,AkinJTJr.Embryologicalconsiderationsofthyroid
surgery:Developmentalanatomyofthethyroid,parathyroid,andtherecurrentlaryngeal
nerve.AmSurg1976;42:621628;withpermission.)
Anatomiclocationsofectopicparathyroidglands,withnumberfoundineachlocation
(n=54).(ModifiedfromShenW,DurenM,MoritaE,HigginsC,DuhQY,SipersteinAE,

ClarkOH.Reoperationforpersistentorrecurrentprimaryhyperparathyroidism.Arch
Surg131:861869;withpermission.)
A,Schematicdrawingsshowingthepositionsoftheparathyroidglandsandtheirvascular
supplyin12caseswith5parathyroidswithoutadenoma.Therightandleftparathyroids
areindicatedseparatelyineachcase.B,Variationsinthelocationoftheparathyroid
glandsinrelationtotheinferiorarteryonbothsidesin354caseswith25glands.The
schematicdrawingsshowalateralviewofthelarynxandtracheawiththethyroid
mobilizedanddislocatedventrallyandmedially.Dottedhorizontallinesindicatethe
levelsoftheentranceoftheuppermostandlowermostbranchesoftheinferiorarteryin
thethyroidparenchyma.Thehatchedareasindicatethelocationoftheparathyroids.For
thesakeofcompleteness,thecaseswithoutaninferiorthyroidarteryarealsoregistered
inseparatedrawings,butinthesethelocationoftheparathyroidisnotshown.(Modified
fromAlverydA.Parathyroidglandinthyroidsurgery.ActaChirScand(suppl)
1968;389:1120;withpermission.)
A.AtoC.Anatomicdistributionof312upperparathyroidglands(parathyroidIV).B.A
toD.Anatomicdistributionof312lowerparathyroidglands(parathyroidIII).(Modified
fromWangC.Theanatomicbasisofparathyroidsurgery.AnnSurg1976;183:271;with
permission.)
Cricothyroidartery(arrow)traversingupperportionofcricothyroidmembrane.
(ModifiedfromDoverK,HowdieshellTR,ColbornGL.Thedimensionsandvascular
anatomyofthecricothyroidmembrane:relevancetoemergentsurgicalairwayaccess.
Clin
Page201of203
Anat1996;9:291295;withpermission.)
Dimensionsofcricothyroidmembrane.Rangeand(mean)valuesreportedinmillimeters.
(ModifiedfromDoverK,HowdieshellTR,ColbornGL.Thedimensionsandvascular
anatomyofthecricothyroidmembrane:relevancetoemergentsurgicalairwayaccess.
ClinAnat1996;9:291295;withpermission.)
Tracheostomytubes:A,Tubetoocurved.Thetrachealwallmaybeerodedandthe
subclavianarterymaybeoccluded.B.Tubeplacedtoolow.Subclavianvesselmaybe
occluded.C,Tubewithcorrectcurvaturecorrectlyplaced.(ModifiedfromSkandalakis
JE,GraySW,RoweJSJr.AnatomicalComplicationsinGeneralSurgery.NewYork:
McGrawHill,1983;withpermission.)
Salivaryglandsandtheirducts.Dissectionshowingthesublingual,submandibular
(submaxillary),andparotidglands.Deeplateralviewofthelingualregionwiththebody
andpartoftheramusofthemandiblecutawaytoexposetheglandsandrelated
structures.(ModifiedfromAnsonBJ(ed).MorrisHumanAnatomy(12thed).New
York:McGrawHill,1966;withpermission.)
Theanatomicrelationsofthebuccalpadoffat.(ModifiedfromTostevinPMJ,EllisH.
Thebuccalpadoffat:areview.ClinAnat1995;8:403;withpermission.)
Diagrammaticrepresentationoftherelationshipoftheparotidglandtothebranchesof
theexternalcarotidartery.(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.

AnatomicalComplicationsinGeneralSurgery.NewYork:McGrawHill,1983;with
permission.)
Diagrammaticrepresentationoftherelationshipoftheparotidglandtotributariesofthe
externalandinternaljugularveins.(ModifiedfromSkandalakisJE,GraySW,RoweJS
Jr.AnatomicalComplicationsinGeneralSurgery.NewYork:McGrawHill,1983;with
permission.)
Schemaoftheparasympatheticinnervationoftheparotidgland.Solidline,preganglionic
pathway.Brokenline,postganglionicpathway.
Secretomotornervetoparotidgland.(ModifiedfromBasmajianJV,SloneckerCE.
GrantsMethodofAnatomy[11thed].Baltimore:Williams&Wilkins,1989;with
permission.)
Sympatheticsupplytotheparotidgland.WRC,whiteramicommunicantes.
Diagrammaticrepresentationoftherelationsoftheparotidglandtothefacialnerveand
itsbranches.(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.Anatomical
ComplicationsinGeneralSurgery.NewYork:McGrawHill,1983;withpermission.)
Superficialdistributionofthefacialnerve.Schematicrepresentationofthetypical
positionsofthebranchesofthefacialnerveinrelationtovisibleorpalpabletopographic
featuresoftheface.A,indicatesthemidpointofalinebetweenthelateralangleofthe
eyeandtheanteriorsurfaceoftheear.Alinefromtheintertragicnotchasshownwill
overliethetemporalbranch.B,indicatesthemidpointofahorizontallinedrawnfromthe
angleofthemandibletojustbelowthelobeoftheear.Alinedrawnfromtheintertragic
notchtothismidpointoverliesthetypicalcourseofthecervicalbranch.
Diagramofthemandibularnerveintheregiondeeptotheramusofthemandible.Inthis
lateralviewtheoticganglion,situatedonthemedialsideofthemandibularnerve,is
indicatedinoutline.Thebranchofthemandibulartothetensorvelipalatini,which
passesmediallythroughtheoticganglion,isnotshown.(ModifiedfromHollinshead
WH.AnatomyforSurgeons(2nded):Vol.1,TheHeadandNeck.NewYork:Harper&
Row,1968;withpermission.)
Superficialanddeepstructuresinthesublingualregion.(Rightandleftindicatethe
sideofthedrawing.)A,SuperficialStructures.Themucosaisintactontheleft;onthe
right,theregionhasbeenclearedofthevesselsandnerves.B,DeepStructures.The
vesselsandnerveshavebeenremovedontheleft,andontherightthevesselsandnerves
areinsitu.
Lateralviewofthesublingualregion.Thebodyofthemandiblehasbeenremoved.
Page202of203
Congenitalcervicoauralfistulaorcyst.Thisisapersistentremnantoftheventral
portionofthefirstbranchialcleft.Thetractmayormaynotopenintotheexternal
auditorycanal.(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.Anatomical
ComplicationsinGeneralSurgery.NewYork:McGrawHill,1983;withpermission.)
Trackofasecondpouchandcleftfistulapassingfromthetonsillarfossaofthepalatine
(faucial)tonsilstotheneck.A,Completefistula.B,External(cervical)andinternal
(pharyngeal)sinuses.C,Cystofbranchialcleftoriginlyinginthecarotidnotch.

(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.AnatomicalComplicationsin
GeneralSurgery.NewYork:McGrawHill,1983;withpermission.)
Incompleteclosureofthesecondbranchialcleftofthepouchmayleavecysts:TypeI,
superficial,attheborderofthesternocleidomastoidmuscle.TypeII,betweenthemuscle
andthejugularvein.TypeIII,inthebifurcationofthecarotidartery.TypeIV,inthe
pharyngealwall.TypesI,II,andIIIareofsecondcleftorigin;TypeIVisfromthe
secondpouch.M,sternocleidomastoidmuscle;V,jugularvein;A,carotidartery.
(ModifiedfromSkandalakisJE,GraySW,RoweJSJr.AnatomicalComplicationsin
GeneralSurgery.NewYork:McGrawHill,1983;withpermission.)
Thecompletedradicaldissectionoftheneck.Remainingstructuresmayberemovedif
theyareinvolvedinmalignantgrowth.(ModifiedfromSkandalakisJE,GraySW,Rowe
JSJr.AnatomicalComplicationsinGeneralSurgery.NewYork:McGrawHill,1983;
withpermission.)
Page203of203