Anatomy Lecture 53

Neck
-Zone I and III highest mortality
-Zone II highest injury
Hyoid: C3. No skeletal articulations
Common carotid artery: bifurcation above laryngeal prominence ~C4-C5
External jugular vein
- In superficial fascia.
-Crosses above SCM
-Drains scalp, side of face
-Blood from:
-Post div of retromandibular vein
-Post auricular vein
-Transverse cervical vein
-Suprascapular vein
-Anterior jugular vein
-Drains to subclavian vein
Platysma in superficial fascia.
Nerve point of neck: Posterior edge of SCM. Cutaneous (sensory) branches of
cervical plexus
-Lesser occipital nerve (C2)
-neck, scalp post. to ear
-Great auricular nerve (C2-C3)
-Skin over parotid gland, mandible to mastoid, ear
-Transverse cervical nerves (C2-C3)
-Anterior neck
-Supraclavicular nerves (C3-C4)
-Skin at clavicle
Posterior rami of C2-C7: Cutaneous branches for posterior neck
Deep cervical fascia: 3 layers
1. Investing layer
a. Invests: SCM and trapezius, and submandibular gland
b. Continuous with capsule of parotid gland
c. Superior attachments: superior nuchal line, mastoid process,
zygomatic arch, inferior border of mandible, cervical spinous
processes/nuchal ligament
d. Inferior attachments: manubrium (ant and post creating a
suprasternal space), clavicles, acromion/spine of scapula
2. Pretracheal
a. Hyoid to thorax: continuous with fibrous pericardium
b. Visceral portion
i. Invests: thyroid gland, trachea, esophagus
ii. Superiorly continuous with buccopharyngeal fascia of
pharynx
iii. Surrounds pharynx
iv. Contacts carotid sheaths (posterolateral), alar fascia (post)
c. Muscular portion

3. Prevertebral
a. Invests vertebral column, muscles
b. Attached to base of cranium
c. Continous with anterior longitudinal ligament (T3)
d. Continuous with endothoracic fascia
e. Forms axillary sheaths laterally
Carotid Sheaths
-Base of cranium to root of neck
Contents (lateral-to-medial)
1. Internal jugular vein (w/ deep cervical lymph nodes)
2. Vagus nerve (CN X)
3. Carotid artery (common or internal)
-with sympathetic fibers
-Joined by alar fascia in retropharyngeal space
*External jugular vein associated with superficial cervical lymph nodes
Retropharyngeal space
-Between visceral pretracheal and prevertebral deep cervical fascia
-Permits independent movement of viscera relative to vertebrae
-Opens to mediastinum; Closed at cranium
Posterior Triangle
-Roof: investing fascia
-Floor: prevertebral fascia layer
-Muscles (floor)
-Splenius capitis, levator scapulae, posterior/middle/anterior scalene
-Inferior belly of omohyoid courses through
-Creates a subclavian (omoclavicular) triangle and occipital triangle
Anterior Triangle
-Roof: subcutaenous tissue, platysma muscle
-Floor: Viscera of neck (pharynx, larynx, throid gland)
-Suprahyoid muscles: hyoid elevators
-Mylohyoid, Stylohyoid, Digastric (anterior and posterior bellies)
-Infrahyoid muscles: hyoid depressors
-Sternohyoid, omohyoid (superior/inferior bellies), sternothyroid,
thyrohyoid
-Triangles within anterior triangle
-Submental triangle: anterior belly of digastric, mandible, midline
-Submandibular triangle: stylohoid, anterior belly of digastric, mandible
-Carotid triangle: SCM, superior belly of omohyoid, posterior belly of
digastric
-Muscular (omotracheal) triangle: Superior belly of omohyoid, SCM,
midline
*Sternohyoid is superficial to Sternothyroid
Anterior scalene: landmark for phrenic nerve, subclavian vessels, brachial plexus,
rib 1
Deep neck muscles
Flexors: longus capitis, longus colli, anterior scalene
Lateral neck flexors: middle scalene, posterior scalene
Interscalene triangle (scalene gap)
-Between anterior and middle scalene

-Conducts subclavian artery and brachial plexus

-Subclavian vein is anterior to anterior scalene muscle
Nerve associations
Accessory nerve (CN XI)
-Deep to SCM, deep to trapezius
-Along levator scapulae
-Runs through posterior triangle
-Damage in posterior triangle diminishes function of trapezius
-No damage to SCM (distal to innervation)
Brachial plexus
-Trunks in posterior triangle
-Coourses through interscalene triangle and cervicoaxillary canal (space
between clavicle/rib 1)
-Suprascapular nerve and nerve to subclavius arise in root of neck
Hypoglossal nerve (CN XII)
-Motor to tongue
-In submandibular triangle
-Deep to posterior belly of digastric
-Carries C1 branches
-Lateral to hypoglossus
Vagus nerve (CN X)
-Within carotid sheath
-Right and left recurrent laryngeal nerves are branches of Vagus nerve
-Asymmetrical
-Innervates muscles of larynx
-Courses along sides of trachea towards pharynx
-Deep to thryoid gland
Cervical plexus
-Partly exposed in posterior triangle
-C1-C4 anterior rami
-Superior rami connect to inferior rami
-Anteromedial of levator scapulae, middle scalene
-Deep to SCM
-Motor branches deep
Ansa cervicalis (C1-C3) - loop
-External to carotid sheath
-Somatic motor to infrahyoid muscles
Phrenic nerve (C3-C5)
-Courses along anterior surface of anterior scalene
-Sensory branches superficial
Sympathetic trunk
-Posterior to carotid sheath
-No white rami communicantes
Three ganglia
Superior: C1-C2, retropharyngeal
Middle
Inferior/Stellate: posterior to origin of vertebral artery
Innervations

Platysma: Cervical branch of Facial nerve (CN VII)

SCM: Motor from Accessory nerve (CN XI)
Sensory from C2, C3 afferent fibers
Mylohoid: Nerve to mylohyoid (branch of CN V3 - mandibular branch of trigeminal
nerve)
Stylohyoid: Stylohyoid branch of facial nerve (CN VII)
Anterior belly of digastric: nerve to mylohyoid (branch of CN V3)
Posterior belly of digastric: Digastric branch of fascial nerve (CN VII)
Sternohyoid: C1-C3 via ansa cervicalis
Omohyoid (superior and inferior bellies): C1-C3 via ansa cervicalis
Sternothroid: C2-C3 via ansa cervicalis
Thyrohyoid: C1 via piggy back on hypoglossal nerve (CN XII)
Longus capitis: C1-C3 anterior rami
Longus coli: C2-C6 anterior rami
Anterior scalene: C4-C6 anterior rami
Middle scalene: Adjacent anterior rami
Posterior scalene: C7-C8 anterior rami
Clinical Correlations
Torticollis: Wry neck. SCM affected.
Congenital: entrapped CN XI. More common. Treated with stretching or SCM
tenotomy
Spasmodic: Twitching, bending. Idiopathic. Resolves with time.
Carotid sheath: Conduit for spread of infection between cranium and mediastinum
Infections in neck fascia
1. Between investing and muscular pretracheal
-Stops at manubrium
2. Between investing and visceral pretracheal
-Spread to anterior thorax
3. Within retropharyngeal space
-Swelling affecting swallowing, speech
-May spread to thorax
4. Posterior to/within prevertebral layer
-Neck swelling posterior to SCM
-Spread to retropharyngeal space