APPLIED SURGICAL ANATOMY OF TRIANGLES OF HEAD &NECK

PRESENTED BY ABHISHEK MOTIMATH

TRIANGLES OF NECK
ANTERIOR TRIANGLE: 1.SUBMENTAL TRIANGLE 2.SUBMANDIBULAR/DIGASTRIC TRIANGLE 3.MUSCULAR TRIANGLE 4.CAROTID TRIANGLE

POSTERIOR TRIANGLES
1. OCCIPITAL TRIANGLE 2.SUBCLAVIAN TRIANGLE

BACK OF NECK TRIANGLE 1.Suboccipital triangle

Anterior Triangle

Posterior Triangle of the Neck

The Neck
Connects the head to the trunk Conduit for blood vessels, nerves, and hollow organs All of these complicated structures are packed in a very narrow area that allows for a great deal of mobility for the head as it moves relative to the ground

FASCIA OF NECK
Superficial fascia: - Connective tissue below dermis - Completely surrounds neck -thin and hard to demonstrate - Contains Platysma & Superficial veins

Deep Cervical Fascia

Form the boundaries of compartments Fascial spaces can communicate infection or fluid to other regions of the body Used as a guide to surgical dissection Allow the neck structures to glide past one another Supports the thyroid, lymph nodes

Deep Cervical Fascia

Deep Cervical Fascia

 Retropharyngeal - b/n prevertebral and buccopharyngeal Pretracheal - b/n infrahyoids and trachea Lateral pharyngeal - lat to pharynx and communicate with RP and SM spaces Submandibular - below tongue
deep portion above mylohyoid superficial portion below mylohyoid

Deep Cervical Fascial Spaces

Anterior Triangle of the Neck

ANTERIOR TRIANGLE Sub mental triangle--formed by the anterior belly of the digastric, hyoid, and midline Submandibular triangle--formed by the mandible, posterior belly of the digastric, and anterior belly of the digastric Carotid triangle--formed by the superior belly of the omohyoid, SCM, and posterior belly of the Digastric Muscular triangle--formed by the

Muscular Triangle

Contents of MUSCULAR TRIANGLE

No significant structure is present Beneath its floor lie thyroid glands,larynx,trachea,esophagus Infrahyoid muscle are present in this triangle
Infrahyoid muscles are arranged in two layers; Superficial sternohyoid and omohyoid Deep-sternothyroid and thyrohyoid

Submental Triangle

Contents of submental triangle

Submental lymph nodes;3 or 4 in no. situated in the superficial fascia below the chin and drains the lymph from the central part of lower lip,adjoining gums,floor of the mouth and tip of tongue Commencement of ant. Jugular vein

DIGASTRIC TRIANGLE

Superficial part of submandibular gland ; Facial vein and submandibular lymph nodes lie superficial to the glands Facial artery;

Contents of digastric triangle

A part of hypoglossal nerve Lower part of parotid gland ,overlapping the posterior belly ECA Carotid sheath

CAROTID TRIANGLE

CONTENTS OF CAROTID TRIANGLE

Arteries; CCA and its two terminal branches internal and external . In the carotid triangle the INT CAROTID is posterolateral while EXT CAROTID is anteromedial CCA and INT CAROTID artery do not give any branches in this triangle

CONTENTS OF CAROTID TRIANGLE

NERVES PRESENT IN THE CAROTID TRIANGLE

Portion of spinal part of accessory nerve Loop of hypoglossal A) Descendens hypoglossi ;supplies the sup. Belly of omohyoid B) Nerve to the thyrohyoid Vagus nerve; passes downward within carotid sheath between IJV laterally and carotid system of arteries medially In fact vagus is not a content of this triangle as it overlapped by SCM

 Internal jugular vein; extends from the base of skull to the root of neck and collects blood from the brain ,superficial part of the face and neck Also present are the tributaries of IJV such as sup. Thyroid, lingual ,common facial, pharyngeal,and sometimes occipital veins

VEINS PRESENT IN THE CAROTID TRIANGLE

Pharyngeal Superior laryngeal Branch to the carotid sinus and body Sup. And inf. Cervical cardiac Right recurrent laryngeal nerve

BRANCHES OF VAGUS NERVE IN THE NECK

CAROTID SHEATH
It is a tubular thickly matted fascial condensation extend from the base of skull to the root of neck. The inferior parts contain several important structures 1) CCA medially 2) IJV laterally 3) Vagus nerve posteriorly 4) Ansa cervicalis 5) Deep Cervical lymph nodes lie along the carotid sheath and IJV 6) Cervical part of sympathetic trunk runs

BRANCHES OF EXTERNAL CAROTID ARTERY IN CAROTID TRIANGLE

Superior thyroid artery Lingual artery Facial artery occipital artery Ascending pharyngeal artery

APPLIED ANATOMY OF CAROTID TRIANGLE

Pulse of carotid triangle by placing the digits in the triangle and compressing the artery slightly against transverse process of the cervical vertebra Carotids sinus ; dilatation of the proximal part of ICA ;acts as baroreceptor Carotid body ;receives rich nerve supply from the glossopharyngeal ,vagus, sympathetic nerves and it act as chemoreceptor Potato tumor of neck is produced by the enlargement of the carotid body. Tumor moves transversely ,shows transmitted pulsation and is often associated with slow

 Vagus nerve and recurrent laryngeal nerves are in risk to damage during surgery in this triangle. Damage to this nerve may produce alteration in the voice When surgery of tongue is to be done and one need to ligate lingual artery then 1st part of the artery present in this triangle is ligated Blind clamping of IJV not done coz vagus and hypoglossal nerve are in vicinity Carotid sheath-can be marked out by a line joining the sternoclavicular joint to a point midway between the tip of the mastoid process and the angle of mandible

 Carotid triangle provides an important surgical approach[1]carotid arterial system [2]internal jugular vein [3]vagus and hypoglossal nerve [4]cervical sympathetic trunk Carotid sinus hypersensitivity-pressure on one or both carotid sinuses results in excessive slowing of heart rate, a fall in blood pressure and cerebral ischemia Arteriosclerosis of internal carotid artery-extensive arteriosclerosis of ICA in the neck can result in visual impairment and blindness in the eye on the side of lesion or even motor paralysis and sensory loss on the opposite side of body Air embolism serious complication of a lacerated wall of the IJV coz the wall of this vein contains little smooth
muscle

 During neck dissection Lower end of internal jugular vein is approached first by dividing the SCM because it is the main vein draining the primary tumor. the carotid sheath is opened to expose the IJV and it is important to identify the length of at least 2cm to facilitate ligation making sure that vagus nerve is not included.the danger of tearing of IJV is not blood loss but air embolism

Upper end of internal jugular vein

Upper end of IJV is important because we have to ligate it during neck dissection .this can be identified by dividing SCM .the position can be located by palpation of transverse portion of atlas over which it lies . Here hypoglossal nerve is to be identified and preserved and can be done as it runs across the ECA ,lingual and facial.

 When ever there is a need to cut omohyoid muscle then it is to be cut through the tendon and at this point transverse cervical artery n vein is encountered and is to be ligated Phrenic nerve and brachial plexus is to be protected, they run behind prevertebral fascia and is safe as long as this fascia is not breached during surgery

Posterior Triangle of the Neck

BOUNDARIES: Front; post. Border of SCM Behind; anterior border of trapeezius muscle Below; inf. Belly of omohyoid Floor; formed from above downward by ; 1)semispinalis capitis muscle 2)splenius capitis 3)levator scapulae 4)scalenus medius and

OCCIPITAL TRIANGLE

Contents of occipital Fourtriangle branches cutaneous

of the cervical plexus
1st;lesser occipital nerve(c2) 2nd;great auricular nerve(c2,c3) 3rd;transverse cervical nerve(c2,c3) 4th ;Supraclavicular nerve(c3,c4) UPPER TRUNK OF BRACHIAL PLEXUS; by c5,c6 roots peeps in occipital triangle between scalenus medius and inferior belly of omohyoid

CONTENTS OF OCCIPITAL TRIANGLE

spinal part of accessory nerve; 3rd and 4th cervical nerve dorsal scapular nerve ;supply rhomboid muscle occipital artery transverse cervical artery and vein

Preservation of Spinal accessory nerve

Whenever we do surgery in the posterior triangle then we have to keep in mind that this nerve runs in the roof and not floor and hence can be damaged during elevation of flap itself. How to identify this nerve; 1.nerve exit point which is called ERBS POINT which is 1cm above point where great auricular nerve winds around SCM on its way to

SUPRACLAVICULAR TRIANGLE

Contents of supraclavicular triangle [1]nerves(a)three trunks of brachial plexus (b)nerve to serratus anterior (c)Nerve to subclavius (d)Suprascapular nerve [2]vessels(a)Third part of subclavian artery and subclavian vien (b)Suprascapular artery and vein (c)Commencement of transverse cervical artery (d)Lower part of external jugular vein [3]lymph nodes(a)Few members of supraclavicular chains

CONTENTS OF POSTERIOR TRIANGLE OCCIPITAL

ARTERY GREAT AURICULAR N. LESSER OCCIPITAL N. ACCESSORY N.

TRANSVERSE CERVICAL NERVE EXTERNAL JUGULAR VEIN

SUPRA CLAVICULA R NERVES

 ERBS POINT- Area of the upper trunk of brachial plexus which is most exposed to shearing force. Here c5 and c6 roots unite to form the upper trunk ,which gives off two branches ,nerve to subclavius and suprascapular nerve. ERBS-DUCHENNE PARALYSIS: commonest type of injury occurring at birth and produced by excessive stretching of upper trunk at the ERBS point from the pressure of forceps used during delivery .the resulting paralysis involves the following muscle supplied by nerve c5,c6;deltoid,supraspinatus,infraspinatu

Applied part of posterior triangle

 KLUMPKES PARALYSIS: takes place due to injury of c8 and TI nerves ,before or after formation of lower trunk. the paralysis affect the intrinsic muscle of the hand ,flexor of the digits producing claw hand .may be caused by pressure of a cervical rib .sometimes sagging of the shoulder girdle due to weakness and fatigue of muscle allows compression of the lower trunk against scalenus anterior muscle .this is called scalenus anterior syndrome INJURY TO THE LONG THORACIC NERVE: sometimes observed in porter who have to carry heavy load on shoulder .the resulting paralysis of serratus anterior is manifested by backward projection of scapula when the arm is held forward ,by the unopposed action

 Palpation and compression of the subclavian artery in patient with upper limb hemorrhage-can be stopped by exerting strong pressure downward and backward on the third part of subclavian artery against the upper surface of first rib Pleura and lung injuries in the root of the neck-cervical dome of the pleura and the apex of the lung extend upto the root of the neck on each side and lie behind subclavian artery so penetrating wound above the medial end of the clavicle may involve the apex of the lung Brachial plexus nerve block-can easily be obtained by closing the distal part of axillary sheath in axilla with finger pressure ,inserting a syringe needle into the proximal part of the sheath and then injecting the local anaesthetic

 Most common swelling in the posterior triangle due to enlargement of the supraclavicular lymph nodes which are commonly enlarged in tuberculosis, Hodgkins disease, and in malignant growth of the breast,arm,or chest Left supraclavicular node or Virchow or scalene nodes involve in malignant growth of distant organ so they are therefore known as signal nodes Torticollis or wry neck in which head is bent to one side and chin points to the other side results from spasm or contraction of SCM ,trapezius supplied by spinal accessory nerve

 Second part of subclavian artery may get compressed by the scalene anterior muscle resulting in decreased blood supply to the upper limb Cervical rib may compress the subclavian artery resulting in diminished radial pulse or obliterated on turning the patients head upward and to the affected side after a deep breath [Adsons test] Dysphagia caused by compression of eosophagus by an abnormal subclavian artery is called Dysphagia lusoria Blalocks operation for fallots tetra logy ,the right subclavian artery is anastomosed end to side to

SUB OCCIPITAL TRIANGLE

Contents of sub occipital triangle

THIRD PART OF VERTEBRAL ARTERY; Here the artery gives muscular branches to supply the sub occipital muscles and meningeal branches to the posterior cranial fossa FIRST CERVICAL NERVE(SUBOCCIPITAL NERVE);supply the muscle of surrounding area SUB OCCIPITAL VENOUS PLEXUS; in and around the sub occipital triangle

 Greater occipital nerve; thickest cutaneous nerve of the body curls around obliquus capitis inferior .it pierces the trapezius muscle and supply the posterior part of scalp up to the vertex. Third occipital nerve; Ascends medial to the greater occipital nerve to supply the back of neck up to the external occipital protuberance Occipital artery; Descending branch of this artery here maintain collateral

Structures related to this triangle

Applied anatomy

Cisternal puncture is often

employed through the sub occipital region to collect CSF from the cisterna magna.the needle pierces the posterior atlanto occipital membrane at a depth of about 4-5 cm (as indicated by sudden loss of resistance ) and enters cisterna puncture

various midline swelling in anterior triangle - (from above downward)

Ludwig's angina Enlarged sub mental lymph nodes Sublingual dermoid Thyroglossal cyst Sub hyoid bursitis Retrosternal goiter

Lateral swellings in the neck

In the submandibular triangle-

1.Enlarged lymph node 2.Enlargement of submandibular gland 3.Deep or plunging ranula 4.Extension of growth from the jaw

IN THE CAROTID TRIANGLE Carotid body tumor Branchial cyst Aneurysm of carotid artery Thyroid swelling Laryngocele Lymph node swelling

IN THE POSTERIOR TRIANGLE

Enlarged supraclavicular nodes Cystic hygroma Pharyngeal pouch Subclavian aneurysm Cervical rib Lipoma

Important neck masses

1.Congenital neck masses Lymphangiomas-occur in infants and children ,tending to be more common in submandibular and supraclavicular region. Midline dermoid-present as solid or cystic masses in the midline of the neck between the suprasternal notch and sub mental region. Treatment is

 Thyroglossal duct cysts-most common midline neck cyst ,mostly painless and moves on swallowing or protruding the tongue with mean age 5 years. Treatment is by excision Thyroglossal duct carcinoma-may be suspected if the cyst is hard and irregular or recently undergoes changes Branchial cyst-2/3 of this is present on left and 1/3 on right side is affected.2/3 lies anterior to the upper third SCM,1/3 in middle and

 Branchial fistula external opening is at the external border of the SCM ,at the junction of the middle and lower thirds and internal opening on the anterior aspect of tonsillar fossa.TRACT runs below the stylohyoid muscle and posterior belly of Digastric above the hypoglossal nerve Haemangiomas-most common benign tumors of infancy and is present most often within the masseter and trapezius muscle

 Ranulas-cystic mass in the floor of the mouth or tongue .plunging ranula result from the extravasattion of mucus below the mylohyoid muscle and present as painless ,non mobile neck swelling Laryngoceles arise within the saccule of the laryngeal ventricle.manual compression may result in the escape of gases and fluid into the airway (BRYCES SIGN) Pharyngeal pouches are also seen

Acquired neck masses

Infective neck masses

Para pharyngeal abscess more common in adults and is complication of tonsillectomy or tonsillitis or extraction of third molar or due to the extension of infection from the petrous part of temporal bone .neck swelling is maximal at the posterior midthird of sternocliedomastoid muscle's/t is I/D the space being opened from a point medial to the mandible to the clavicle

 AIDS-head and neck manifestation are seen Toxoplasmosis-caused by toxoplasmosis Gondi Actinomycosis Infectious mononucleosis Brucellosis Tuberculous cervical lymphadenitislong standing lymphdenopathy due to tuberculosis ,usually the deep jugular chain ,although the posterior triangles nodes can also be affected

REFERENCE
TEXTBOOK OF ANATOMY: B.D.CHAURASIA GRAYS ANATOMY TEXTBOOK OF ANATOMY: A.K.DUTTA ATLAS OF HUMAN ANATOMY : FRANK NETTER