Download Deep dissection of the neck

Deep dissection of the neck
2017 spring
Outline
• Prevertebral muscles
- Anterior vertebral muscles
- Lateral vertebral muscles
• Root of neck
• Viscera of neck:
- thyroid gland
- parathyroid gland
Anterior
Prevertebral muscles: Flex head & neck
- Anterior vertebral muscles
- Lateral vertebral muscles
Separated by the Neurovascular
plane
Longus coli
Ant. Scalene m.
Middle Scalene m.
Levator scapula m.
Anterior vertebral muscles
Lie posterior to retropharyngeal space
1. Longus colli
2. Longus capitis
3. Anterior scalene
4
C1
Longus capitis
2
Longus colli
Transverse process C3-6 1st rib
4. Rectus capitis anterior
C3
Ant. scalene
1
Weak flexor of c- spine
C5
3
3
#
T3
1st rib
Innervation (N):
Cervical spinal nerves
1
*
*
Anterior
scalene
Transverse process C3-6 1st rib
Lateral vertebral muscles
Floor of the posterior cervical region
1. Rectus capitalis lateralis
2. Middle scalene
3. Posterior scalene
4. Levator scapularis
5. Splenius capitalis
5
SCM
4
3
Trapezius
2
1
5
Levator scapulae
Transverse processes, C2-C6 medial border of scapula
Elevate the scapula; Downward rotation of scapula
Dorsal scapular nerve (C5), spinal nerves C3,C4
Splenius capitis
Levator scapulae
Splenius capitis
Lat.1/3 of sup. nuchal line, lat. mastoid processnuchal lig., T1-6 spinous proc.
Splenius capitis
Laterally flexes and rotates head/ neck
Root of the neck
• Junction area : the thorax and the neck
• On the cervical side of superior thoracic aperture
• Neurovascular elements and visceral structures
Cervical axillary canal
T1
Superior thoracic aperture
M
Superior thoracic aperture : manubrium- 1st rib- T1
Anterior scalene muscle:
the landmark
Veins at the root
Internal
jugular vein
subclavian
vein
subclavian v.
Brachiocephalic vein
(innominate vein)
Veins at the root
Subclavian vein
•Venous angle (*) : thoracic duct (left), lymphatic trunk (right)
*
*
Ant. scalene ms.
1st rib
Brachiocephalic vein
Arteries at the root
Subclavian artery
1.
•
•
•
First part
Vertebral a.
Internal thoracic a.
Thyrocervical trunk
2. Second part
• Behind ant. Scalene
• Costocervical trunk (1 -2
st
nd
intercostal spaces; deep cervical muscles)
3. Third part
• Dorsal scapular a. (arterial
anastomosis of the scapula)
12
Thyrocervical trunk
Subclavian a.
Internal thoracic a.
Vertebral artery
Cervical part
•
Between scalene and longus m.
• F. transversaria, C1-C6
Vertebral part
Suboccipital part
Post. Arch of atlas
Cranial part
Join  basilar a.
www.chiro.org/LINKS/stroke.shtml
Thyrocervical trunk
•IT: Inferior thyroid a.
•TC: transverse cervical a.
MS
AS
•SS: supra-scapular a.
Ascending
cervical a.
I.T
T.C
S.S
Scapular arcade
(Right side, posterior view)
Suprascapular a.
Suprascapular a.
Dorsal scapular a.
Circumflex scapular a.
Nerves in root of neck
Vagus nerve; phrenic nerve; sympathetic trunk
Vagus nerve
• Jugular foramen; carotid sheath
• Right vagus nerve
right
- Anterior to subclavian a.
• Left vagus nerve
- between common carotid a. and
subclavian a.
NG: nodose ganglion
Recurrent laryngeal nerves
Three cervical branches of vagus
mid. constrictor
1. pharyngeal br. (p) – mid. constrictor
2. Sup. laryngeal nerve(sl)
•
internal branch
– mucous membrane above vocal fold
•
external branch
– cricothyroid
m. &
inf. Constrictor
3. recurrent laryngeal n. (rl)
- right ->loop subclavian a.;
- left-> loop arch of aorta
- posteromedial aspect of thyroid
- mucous memb. below vocal fold
18
- all intrinsic m. (except: cricothyroid)
Actions of intrinsic muscles of larynx
Cricothyroid muscle
Cervical sympathetic trunk
•on prevertebral fascia, anterolateral to vertebral column
•Include 3 sympathetic ganglia
Superior cervical ganglion:
at level of C1 & C2 vertebrae
Larger, landmark
Middle cervical ganglion:
at anterior aspect of inf. thyroid a.
(C6)
Superior cervical
sympathertic ggl.
Inferior: (at transverse proc.,C7)
80% fuses with 1st thoracic gang.
Cervicothoracic ganglion
(stellate ganglion)
Cardiac/peri-arterial plexus
Stellate ganglion
21
Thyroid gland
•
•
•
•
Deep to sternohyoid & sternothyroid muscles.
Lie on cricoid cartilage and superior trachea ring
Two lateral lobes, connected by isthmus
Pyramidal lobe (50%): inferior end of thyroglossal duct
Hyoid
Thyrohyoid
membrane
Cricoid
cartilage
Thyroid
cartilage
Trachea
Thyroid gland
• attach to cricoid cartilage & superior tracheal rings
• Move as one with the larynx and trachea
Hyoid bone
後
前
Thyroid cartilage
CC: Cricoid cartilage
TS: thyroid sheath
= pretracheal fascia
TCA: thyroid capsule
Venous drainage of the thyroid gland
• Superior thyroid veins (2)
 internal jugular v.
• Middle thyroid veins (2)
 internal jugular v.
Superior thyroid
artery and vein
Middle thyroid
vein
• Inferior thyroid veins (2)
 Brachiocephalic vein
Inferior thyroid
vein
Arterial supply
-Superior
thyroid artery
1st branch
of external carotid a.
Sup. thyroid v. accompanied
-Inferior thyroid artery
branch of thyrocervical trunk
posterior to carotid sheath
recurrent laryngeal nerve
ITA
Right side
(左前 右後)
Right side
Thyroid ima artery
~10% of people
small, unpaired;
from brachiocephalic trunk(or other)
Pyramidal lobe
~50% of thyroid glands have a
pyramidal lobe
27
Nerves of thyroid gland
Cervical sympathetic ganglia
 peri-arterial plexuses
 vasomotor: constriction of
blood vessels
28
Parathyroid gland
•Small, oval glands
•Usually “4”
•superior and inferior parathyroid
•external to fibrous thyroid capsule
•medial half of posterior surface
Locate the parathyroid glands:
-point of entry: thyroid arteries
Posterior view
Parathyroid glands
• could be anywhere
• from the pharynx to the superior mediastinum
Sites & frequency of
aberrant parathyroid
glandular tissue.
30
Discovery of the parathyroid gland:
The glands of Owen
Hunterian Museum, Royal College of Surgeons, London
Arterial supply
- Inferior thyroid artery
Venous drainage
-thyroid plexus of veins
Superior parathyroid gland
Inferior thyroid a.
Inferior parathyroid gland
32
Lymphatic system of the neck
• Superficial lymph nodes
• Deep lymph nodes
Level
Lymph nodes (L.N)
Drainage region
I
Submental,
submandibular
Face
II,III,IV
Lateral jugular
group
Laryngo-tracheal-thyroidal;
nuchal
V
Posterior triangle
Nuchal
VI
Anterior triangle
Laryngo-tracheal-thyroidal
Lymphatic drainage of the thyroid gland
Lymphatic vessels in interlobular connective tissue
 prepharyngeal, pretracheal,
& paratracheal lymph nodes
 superior & inferior deep
cervical lymph nodes
34