B6-092 Triangles of the Neck Flashcards
what vertebral level is the body of the hyoid located at?
C3-C4
what vertebral level is the bifurcation of the common carotid located at?
C3-C4
what vertebral level is the superior end of the esophagus/trachea located at?
C5-C6
what vertebral level is the arch of the cricoid located at?
C5-C6
what borders make up the anterior triangle of the neck?
midline of neck
sternocleidomastoid
lower border of mandible
what borders make up the posterior triangle of the neck?
sternocleidomastoid
trapezius
clavicle
what borders make up the submandibular sub-triangle?
anterior belly of digastric
posterior belly of digastric
inferior border of mandible
what borders make up the submental sub-triangle of the neck?
midline of neck
anterior belly of digastric
body of hyoid
what borders make up the muscular sub-triangle of the neck?
body of hyoid
superior belly of omohyoid
sternocleidomastoid
what borders make up the carotid sub-triangle of the neck?
posterior belly of digastric
superior belly of omohyoid
stenocleidomastoid
what level of the neck do the submental and submandibular lymph nodes lie in?
level 1
what level of the neck do the jugular lymph nodes lie in?
2-upper third
3- middle third
4-lower third
what level of the neck do the posterior triangle lymph nodes lie in?
level 5
what level of the neck do the central neck lymph nodes lie in?
level 6
what muscles run through the floor of the posterior triangle? [6]
splenius capitis
levator scapulae
posterior scalene
middle scalene
anterior scalene
omohyoid
the […] exits between the middle and anterior scalene muscles in the posterior triangle
roots of the brachial plexus
arteries in the posterior triangle are branches of the […]
subclavian
the right subclavian is a branch from the
brachiocephalic trunk
the left subclavian branches from the
arch of the aorta
first branch off the subclavian
internal thoracic (mammary)
branches of the thyrocervical trunk and what they supply [5]
inferior thyroid: thyroid
superior transverse cervical: trapezium
deep branch of transverse cervical (dorsal scapular): levator scapulae & rhomboids
suprascapular: supra/infraspinatus
vertebral artery: brain
the thyrocervical branches from the
subclavian
artery that travels through the transverse foramen starting at C6
vertebral artery
where many of the cutaneous branches of the cervical plexus exit posterior to the middle third of the sternocleidomastoid
Erbs point
4 branches of the cervical plexus
lesser occipital
greater auricular
transverse cervical
supraclavicular
supplies sensation to the skin of the back of neck and the scalp posterior superior to the ear
lesser occipital
innervates the inferior parotid gland
great auricular
supplies sensation to the angle of the mandible and a portion of the external ear
great auricular
supplies sensation to the skin of the anterior neck
transverse cervical
supplies sensation to the skin of the shoulder and clavicle
supraclavicular
cranial nerve 11
spinal accessory
supplies motor to sternocleidomastoid and trapezius
spinal accessory
susceptible to damage during lymph node biopsy in the posterior triangle
spinal accessory
supplies cutaneous sensation to the auricle, the angle of the mandible, and the inferior portion of the parotid gland
great auricular
supplies cutaneous sensation to the skin of the back of the head
lesser occipital
travels through the fascia of the posterior triangle and is susceptible to damage from lymph node biopsy
spinal accessory
exits between the anterior and posterior scalene muscles
roots of brachial plexus
what nerve lies anterior to the anterior scalene
phrenic nerve
supplies innervation to the diaphragm
phrenic
what vessels travel anterior to the anterior scalene [3]
transverse cervical a.
suprascapular a.
subclavian v.
the subclavian […] lies anterior to the anterior scalene and the […] lies posterior
vein is anterior
artery is posterior
**important to central line placements
contraction of sternocleidomastoid muscle
tortocollis
**causes head to tilt toward and face away from affected side
created when the retromandibular vein joins the posterior auricular vein near the angle of the mandible
external jugular vein
vein located anterior to the anterior scalene
subclavian
subclavian vein unites with internal jugular to create
brachiocephalic vein
suprahyoid muscles of anterior triangle[4]
anterior/posterior belly of digastric
stylohyoid
mylohyoid
genioglossus
infrahyoid muscles of the anterior triangle [4]
sternohyoid
thyrohyoid
sternothyroid
omohyoid
**AKA strap muscles
what muscles depress the hyoid and larynx during swallowing/speaking?
infrahyoid (strap) muscles
what muscles elevate the hyoid and larynx during swallowing/speaking?
suprahyoid muscles
at the level of C3-C4, the carotid branches into [2]
external carotid
internal carotid
what branch of the carotid has no other branches and until it reaches the brain?
internal carotid
all artery branches seen in the anterior triangle are branches from
external carotid
branch of external carotid artery that supplies the thyroid
superior thyroid
artery from the external carotid that helps supply the larynx
superior laryngeal artery
artery that supplies the tongue
lingual (via external carotid)
branch of external carotid that supplies the face
facial artery
artery located on the posterior aspect external carotid that supplies the pharynx
ascending pharyngeal artery
artery that supplies the posterior scalp and some meninges
occipital artery (via external carotid)
the occipital artery (via external carotid), has a close relationship to what nerve?
cranial nerve 12 (hypoglossal)
terminal branches of the external carotid [2]
maxillary a.
superficial temporal a.
identify the vessels in the image
.
what nerve lies in the submandibular triangle?
hypoglossal
what artery and vein lie in the submandibular triangle?
facial a. and v. (pass anterior to mandible)
lingual artery also lies here
innervates the tongue and helps to protrude the tongue
hypoglossal
if hypoglossal is damaged, what deficit is observed?
tongue with deviate to damaged side
the […] vein starts in the submental triangle
anterior jugular
the thyroid and parathyroid lie in which anterior sub-triangle?
muscular
structures contained in the carotid sheath [3]
(located in carotid triangle)
common carotid artery
internal jugular vein
vagus nerve
most posterior structure in the carotid sheath
vagus nerve
the […] is located anterior medial within the carotid sheath
common carotid
the […] is located posterior lateral within the carotid sheath
internal jugular vein
[…] nerve travels with lingual artery in the carotid and submandibular triangles
hypoglossal
innervates the strap muscles
ansa cervicalis
what nerves lie in the superior portion of the carotid triangle?[3]
hypoglossal
spinal accessory
superior root of ansa cervicalis
superior root of ansa cervicalis travels with
hypoglossal
nerves exiting the jugular foramen near carotid sheath [3]
glossopharyngeal (CN IX)
vagus nerve (CN X)
spinal accessory (CN XI)
structures located at the bifurcation of the common carotid [2]
carotid sinus and body
the carotid sinus is innervated by [2]
glossopharyngeal (CN 9)
vagus
baroreceptor that responds to changes in blood pressure
carotid sinus
chemoreceptor that monitors oxygen levels
carotid body
CN 10
vagus
CN 11
spinal accessory
CN 12
hypoglossal
what nerve lies in close approximation to the occipital artery?
hypoglossal
what nerve travels with hypoglossal nerve?
superior root of ansa cervicalis
[…] nerve comes from C2-C3
inferior root of ansa cervicalis
innervates infrahyoid (strap) muscles
ansa cervicalis
[…] trunk of brachial plexus is in close approximation to the first rib
inferior
structures that are compressed in thoracic outlet syndrome
inferior trunk of brachial plexus
subclavian artery
subclavian vein
issues with intrinsic muscles of hands
problems in C8/C1 dermatomes
decreased pulse in one limb
thoracic outlet syndrome
apex of the lungs is located
in the root of the neck
thoracic duct drains into the
venous angle
brings lymph from lower limbs, pelvis and perineum, abdomen, left side of chest, left extremity, left head and neck to dumb into venous angle
thoracic duct
the subclavian […] lies anterior to the anterior scalene
vein
the subclavian […] lies posterior to the anterior scalene
artery
what structures might be injured in central line placement?
subclavian vein
subclavian artery
lung
nerve that lies on the anterior surface of anterior scalene
phrenic
damage to the sympathetic chain results in
Horner’s syndrome
miosis
ptosis
anhidrosis
Horner’s syndrome
injury to the phrenic results in
asymmetrical lifting of the diaphragm
occlusion of the subclavian artery proximal to the origin of the vertebral artery results in
subclavian steal syndrome
blood “stolen” from cerebral circulation to perfuse arm
subclavian steal syndrome
hyperextension or severe rotation of the neck compresses the […] artery between the occipital bone and the posterior arch of C1
vertebral
**vertebrobasilar insufficiency
compression of the vertebral artery between the occipital bone and the posterior arch of C1
vertebrobasilar insufficiency
main component of the subcutaneous layer of the superficial fascia
platysma muscle
platysma is innervated by
CN 7 Facial
which layer of the fasica encloses sternocleidomastoid and trapezius?
investing layer
which layer of the fasica encloses parotid and submandibular glands?
investing layer
which layer of the fasica is the most superficial?
investing layer
which layer of the fasica is located in the anterior region of the neck?
pretracheal layer
which layer of the fasica blends with the pericardium of the heart?
pretracheal layer
which layer of the fasica encloses the infrahyoid muscles, larynx, thyroid gland, and trachea?
pretracheal layer
which layer of the fasica encloses the vertebral column/muscles?
prevertebral layer
which layer of the fasica extends as the axillary sheath into the arm?
prevertebral layer
contents of the carotid sheath? [3]
common carotid artery
internal jugular vein
vagus nerve
nerve that lies posterior to carotid sheath and anterior to anterior scalene
phrenic
lies medial to the carotid sheath and ascends to the head
sympathetic chain
borders of the retropharyngeal space
buccopharyngeal fascia (anterior)
prevertebral fascia (posterior)
carotid sheath (lateral)
potential space posterior to the pharynx
retropharyngeal space
can result from lymphatic drainage, URTI, or oral infections
retropharyngeal abscesses
swelling of a […] can cause difficulty speaking and swallowing and can be life threatening
retropharyngeal abscess
the lymphatics of the scalp/superior head drain into the
superficial ring (pericervical collar)
the lymphatics of the superficial ring (pericervical collar) drain into the
deep cervical nodes
deep cervical nodes [2]
jugulo-digastric (C3)
jugulo-omohyoid (C6)
lymph node at C3
jugulo-digastric
lymph node at C6
jugulo-omohyoid
the laryngeal nodes superficial to the vocal folds drain into the
superior deep cervical nodes
the laryngeal nodes inferior to the vocal folds drain into the
pretracheal or paratracheal lymph nodes
the thyroid nodes drain into the
prelaryngeal, pretracheal or paratracheal nodes
drains lymph from right side of head and neck, right side of the thorax, and right extremity
right lymphatic duct
**everything else goes to thoracic duct
structure from C5-T1
thyroid
connects the right and left lobes of the thyroid
isthmus
lobe of the thyroid that extends to hyoid bone that may be present due to embryological development
pyramidal
main blood supply of thyroid [2]
superior thyroid (via external carotid)
inferior thyroid (via thyrocervical trunk of right subclavian)
artery stemming from the brachiocephalic trunk that supplies the thyroid in 10% of people
thyroid ima artery
artery that could be injured during tracheostomy
thyroid ima artery
**only 10% of people have this
right recurrent laryngeal wraps around
right subclavian artery.
left recurrent laryngeal wraps around
aortic arch
the recurrent laryngeal arteries are branches off
vagus
during thyroid surgery, what nerves lie in close proximity and could be damaged?
recurrent laryngeals
help to maintain calcium homostasis
parathyroid glands
cartilage located at C4
thyroid
cartilage located at C6
cricoid
an aperture in the […] allows the superior laryngeal a. and n. to supply the larynx
thyrohyoid membrane
lies between the thyroid and cricoid cartilage
clinically significant to cricothyrotomy
cricothyroid membrane
the incision for a tracheostomy should be between the […] and […] rings
2nd and 4th
false vocal cords
vestibular folds
area between the laryngeal inlet and the vestibular folds
laryngeal vestibule
area between the vestibular folds and vocal folds
laryngeal ventricle
area between the vocal folds and cricoid arch
intraglottic space
opening between the vocal folds
rima glottidis
tenses the vocal ligaments giving a high pitched voice
cricothyroid
cricothyroid muscle is innervated by
external laryngeal nerve (via CN X)
all laryngeal muscles except for the cricothyroid are innervated by
recurrent laryngeal
**cricothyroid is innervated by external laryngeal
abducts (opens) the rima glottidis
posterior crico-arytenoid
adduct (close) rima glottidis and vocal folds [3]
transverse arytenoid
oblique arytenoid
lateral crico-arytenoid
muscle that relaxes vocal cords to deepen or lower pitch of voice
thyro-arytenoid
forced respiration activates the […] to abduct
posterior crico-arytenoid
phonations activates what muscles to close the vocal cords?
lateral crico-arytenoid
transverse arytenoid
oblique arytenoid
whispering activates what laryngeal muscles?
lateral crico-arytenoid
**oblique and transverse are relaxed to provide posterior opening
what two structures pierce the thyrohyoid membrane to supply the larynx?
internal branch of superior laryngeal
superior laryngeal artery
if the superior laryngeal artery is ligated during a thyroid surgery, what nerve is at risk?
internal branch of superior laryngeal
innervates the cricothyroid muscle
external branch of superior laryngeal
provides sensation above the vocal fold
internal branch of the superior laryngeal
if water goes down the “wrong tube”, what nerve initiates the cough reflex?
internal branch of the superior laryngeal
provides sensation below the vocal cord
recurrent laryngeal
lymphatic vessels superior to the vocal folds drain into the
superior deep cervical lymph nodes
lymphatic vessels inferior to the vocal folds drain into the
pretracheal/paratracheal –> inferior deep cervical nodes
arteries of the posterior triangle [3]
suprascapular
transverse cervical
dorsal scapular
arteries of the anterior triangle [5]
common carotid (internal and external)
superior thyroid
superior laryngeal
lingual
facial
runs in the investing layer of deep cervical fascia, forming the roof of the posterior triangle
spinal accessory
Erb’s point is located…
posterior to the middle third of the SCM
cutaneous branches of the cervical plexus exit at
Erb’s point
the transverse cervical supplies cutaneous sensation to
skin of anterior neck
the great auricular supplies cutaneous sensation to [4]
skin over parotid
mastoid process
auricle
angle of mastoid
the lesser occipital supplies cutaneous sensation to
skin of the neck and scalp posterior to auricle
the suprascapular supplies cutaneous sensation to
skin over clavicle and shoulder
spinal accessory supplies motor to [2]
SCM
trapezius
in torticollis, the neck tilts to the […] and the face looks to […]
neck tilts to same side
face looks to opposite side
a lesion in […] causes deviation of the tongue toward the injured side on protrusion
hypoglossal
supplies taste sensation to the anterior 2/3 of tongue
facial
supplies taste sensation and general sensation to posterior 1/3 of tongue
glossopharyngeal
supplies general sensation to anterior 2/3 of tongue
lingual
supplies taste sensation to base of tongue and epiglottis
vagus
what layer of fascia surrounds the muscles on the floor of the posterior triangle?
prevertebral
what layer of fascia surrounds the SCM and trapezius?
investing
what layer of fascia surrounds the infrahyoid muscles, the thyroid gland, larynx, trachea, and esophagus?
pretracheal
located anterior and medial in the carotid sheath
common carotid
located anterior and lateral in the carotid sheath
internal jugular
innervates all the laryngeal muscles except cricothyroid
recurrent laryngeal
cricothyroid is innervated by
external laryngeal
provides sensory to larynx above vocal cord
internal laryngeal nerve
nerve that is vulnerable to injury in thyroidectomy
recurrent laryngeal
superior thyroid a. branches from
external carotid a.
does not have any branches in the neck or face
branches once it reaches brain
internal carotid a.
ligation of the subclavian artery or thyrocervical trunk would stop bleeding from the
inferior thyroid a.
cancer/infection from the infraglottic cavity (below the vocal folds) would travel first to what lymph node?
pre/paratracheal
cancer/infection from the supraglottic cavity (above the vocal folds) would travel first to what lymph node?
superior deep cervical lymph nodes
infection of the palatine tonsils would travel first to what lymph node?
jugulo-digastric
cancer/infection of the thyroid would travel first to what lymph nodes? [3]
prelaryngeal
pretracheal
paratracheal
tensing of the cricothyroid will result in
high pitched voice
the lateral crico-arytenoid […] the vocal cords
adducts
the posterior crico-arytenoid […] the vocal cords
abducts
the thyro-arytenoid relaxes the vocal ligament causing
deep voice
adduct the arytenoid cartilage that closes the posterior rima glottidis [2]
transverse and oblique arytenoids
how would you evaluate for suspected outlet syndrome?
check bilateral pulses and sensation/symmetry
the inferior trunk lies in close proximity to the
1st rib
**can become compressed causing thoracic outlet syndrome
3 points of compression of the brachial plexus
scalene triangle
costoclavicular space
pectoralis minor space
most common thyroid cancer
papillary thyroid carcinoma
what muscles will be retracted during thyroidectomy? [2]
sternothyroid
sternohyoid
what arteries should be visualized and ligated during thyroidectomy? [4]
superior and inferior thyroid
thyroid ima
superior laryngeal
what veins should be visualized and ligated during thyroidectomy? [3]
superior, middle, inferior thyroid veins
what layers of fascia would be incised during thyroidectomy? [2]
investing
pretracheal
superior thyroid artery comes off
external carotid
inferior thyroid artery comes off
subclavian via thyrocervical trunk
superior and middle thyroid veins drain into
internal jugular
inferior thyroid vein drains into
brachiocephalic trunk
hypocalcemia following thyroidectomy is due to injury of
parathyroid
hoarse voice following thyroidectomy is due to injury of
recurrent laryngeal n.
high pitched voice following thyroidectomy is due to injury of what nerve?
external branch of superior laryngeal
vocal cord paresis or paralysis following thyroidectomy is due to injury of
recurrent laryngeal n.
horner syndrome following thyroidectomy is due to injury of
sympathetic chain
chyle fistula following thyroidectomy is due to injury of
thoracic duct
breathing difficulties following thyroidectomy is due to injury of
trachea
dysphagia following thyroidectomy is due to injury of
esophagus
external branch of superior laryngeal innervates
cricothyroid
in carotid sheath:
lateral
medial
posterior
lateral: internal jugular vein
medial: common carotid artery
posterior: vagus
provides sensory above the vocal folds
internal branch of superior laryngeal
external branch of superior laryngeal travels with
superior thyroid artery
**if artery is ligated during surgery, patient will be unable to make high pitched voice
cancer in the […] region of the larynx is most likely to cause voice changes
glottic
in the case of laryngeal cancer, the vagus nerve can refer pain to the
ear
what supplies blood to the superior larynx?
superior laryngeal a.
cutaneous nerve supply to superior larynx
internal branch of superior laryngeal
**important to cough reflex
lymphatic supply of superior larynx
superior deep cervical nodes
blood supply to inferior portion of larynx
inferior laryngeal a.
nerve supply to inferior portion of larynx
inferior laryngeal n.
lymphatics of inferior portion of larynx
pretracheal/paratracheal
how does swallowing affect the thyroid and lymph nodes?
thyroid moves
lymph nodes do not
**able to differentiate location of nodule
lymph nodes near hyoid at C3/4
jugulodigastric
lymph node near cricoid cartilage at C6
jugulo-omohyoid
tonsils drain to what lymph nodes?
jugulodigastric
nerve that emerges from the posterior border of SCM and crosses the posterior triangle close to the subq
spinal accesory
leaves the cranium through the jugular foramen and winds around the stylopharyngeous muscle and passes between the superior and middle constrictor muscles
glossopharyngeal IX
emerges from the inferior border of the parotid gland and passes anteriorly in the neck inferior to the mandible to supply the platysma
cervical branch of facial VII
injury to […] causes the skin to fall away from the neck in slack folds
cervical branch of facial VII
muscle located between the sternum and the hyoid bone that covers the thyroid gland
sternohyoid
muscle located between the cricoid cartilage and the thyroid cartilage that is superior and deep to the thyroid gland
cricothyroid
muscle located between mandible and hyoid bone that is superior to the thyroid gland
mylohyoid
muscle located between the hyoid bone and the clavicle that is found lateral to the thyroid gland
omohyoid
muscle that attaches to the hyoid bone and thyroid cartilage that is found superior to the thyroid
thyrohyoid
[…] fascia extends inferiorly from the hyoid to the thorax to blend with pericardium
pretracheal
layer of fascia that surrounds the thyroid, trachea, esophagus, and recurrent laryngeal nerve
pretracheal
layer of fascia that surrounds the SCM, trapezius and parotid/submandibular glands
investing
layer of fascia that extends from base of skull to mastoid process, zygomatic arches, and inferior mandible
investing
layer of fascia that surrounds the vertebral column, associated muscles, and phrenic nerve
prevertebral
potential space in the neck where infection can spread; extends from base of skull to mediastinum
retropharnygeal
if the vagus is damaged at the C3-C4 level of carotid bifurcation, what is the result
hoarse voice
sympathetic trunk is located […] to carotid sheath
medial
damage to the [….] results in the inability to shrug the ipsilateral shoulder
spinal accessory XII
nerve located posterior to carotid sheath
phrenic
damage to […] results in the paralysis of ipsilateral diaphragm
phrenic
four branches of subclavian artery
Vertebral
Internal thoracic
Thyrocervical trunk
Costocervical trunk
VIT C
in subclavian steal syndrome, blood is shunted through what artery?
ipsilateral vertebral a.
the lymphatic vessels superior to the vocal folds empty into the
superior deep cervical nodes
the lymphatic vessels inferior to the vocal folds empty into the
pretracheal/paratracheal nodes –> inferior deep cervical
the thyroid lymphatics drain into the […] nodes [3]
prelaryngeal
pretracheal
paratracheal
what lymph node is frequently enlarged when the tonsils are inflamed?
jugulodigastric
loss of the […] can result in aspiration of liquids into the lungs instead of initiation of cough reflex
internal branch of superior laryngeal n.
what neurovascular pair can be injured during thyroidectomy?
internal branch of superior laryngeal n.
superior thyroid a.
internal branch of superior laryngeal n. travels with the […] artery
superior thyroid
provides motor to the cricothyroid muscle which tenses the vocal ligament
external branch of superior laryngeal
innervates all intrinsic muscles of the larynges except cricothyroid
recurrent laryngeal
nerve that supplies sensation below the vocal cords
recurrent laryngeal
innervates the intrinsic muscles of the tongue
hypoglossal
provides sensation to the pharynx, posterior 1/3 of tongue, posterior ear, and soft palate
glossopharyngeal
what muscle abducts the vocal cords to allow the passage of air
posterior crico-arytenoid
only muscle to abduct vocal cords
posterior crico-arytenoid
relaxes the vocal ligament resulting in deep pitched voice
thyro-arytenoid
close the posterior rima glottidis [2]
transverse and oblique arytenoids
