Neck Flashcards
What are the important bony landmarks of the neck?
External occipital protuberance
Mastoid process (hollow bone)
Transverse process of C2
Hyoid bone
Inferior border of cricoid cartilage
The hyoid bone is located at which vertebral level?
C3-C4
(it floats)
The inferior border of cricoid cartilage can be located at which vertebral level?
C6
The inferior border of the cricoid cartilage is an important landmark because this where the _____ transitions into the esophagous and the _____ transitions into the trachea.
Pharynx
Larynx
The key landmark for organizing the neck is?
Sternocleidomastoid
The Sternocleidomastoid muscle has two heads. What are they?
Clavicular head
Sternal head
What type of contraction allows the head to turn toward the opposite side of that contraction?
Unilateral Contraction of SCM
What are the actions of the SCM?
Unilateral Contraction
Lateral flexion (ipsilateral
contralateral rotation
Bilateral Contraction
extend the atlanto-occiptal joint
(if neck is fixed)
Bilateral contraction
Flexed the neck
(if atlanto-occipital join is fixed)
Name the muscles than can mask paresis of the sternomastoid?
????
How do you test the action of the SCM?
Test it against resistance by asking the patient to turn their head left and right.
(testing against resistance is used because other muscle can compensate for irs paralysis)
Compare on both sides
During delivery, the muscle fibers of the sternocleidomastoid may be torn and damaged as the baby’s body is removed too vigorously while the head remains in the birth canal.
How can this be avoided?
Placing a finger in the baby;s mouth and pulling gently
What happens if the SCM is damaged during Child birth?
This can lead to a condition known as
Torticollis Congenital (Wry Neck)
After tearing, muscle fibers are replaced with scar tissue. The scarred muscle does not lenthen as the baby;s neck grows. Thus, the head becomes progressively twisted toward the opposite side.
What is spasmotic Torticollis?
Lesion in the Central nervous systerm can lead to spontaneous contraction of the SCM. These twitches are gross twitch and can be minimized by holding the chin. The Basal ganglia is affected (further info in later unit)
Which vein crosses the SCM and enters into the deep cervical fascia?
The external jugular vein
(it is a superficial vein)
After piercing the deep cervical fascia it terminates in the subclavian vein.
What happens if the External jugular vein is cut while in the deep cervical fascia?
The deep cervical fascia is a tight fascia so when the vein is cut, instead of collapsing, it is held open by the fascia. This allows the heart to in an air emobolism (plug) filling the right heart with froth -> pulmonary embolism
The deep cervical fascia covers which two muscles?
The SCM and Trapezius
The external jugular vein can serve as an internal _____.
Barometer
Valsava maneuver is something we do commonly, ecspellialy when working out, what does it do to the external jusular vein.
The increase pressure on the veins draining into the heart causes buldging on the EJV.
What can be used as a sign to lead to a diagnosis of right heart failure?
Dilation of external jugular vein
Venous Pressure is suppose to only be a couple of m above 0
What is superior vena cava syndrome?
Blockage of the superior vena cava by a tumor may cause the external jugular to become distended.
Why is fast administration of IV fluids dangerous to a patient?
This can overload the kidney causing a backflow of fluid in the body. It is key to moitor the external jugular vein. If buldging occurs decrease fluid rate. It is a key indicator in knowing that the patient is recieveing to much fluid. (possitioning the patient is critical is assesing the EJV)
Posterior to the external jugular vein is something know as the “Nerve Point of the Neck”, what is the relationship to othe SCM?
The “nerve point of the neck” is found along the middle 1/3 of the posterior border of the sternomastoid.
What are the 4 major nerves that are part of the “nerve point of the neck”?
Greater auricular n.
Lesser Occipital n. (going to back of occipital bone)
Transverse cervical n. (sensory for anterior clavicle_
Supraclavicular n. (skin over clavicle)
These are sensory branches of cervical plexus
Injections of anesthetitc at the nerve point of the neck is known as?
Cervical Plexus block
Cervical Plexus is from ____ to ____.
C1 to C4
What are the sensory branches of the cervical plexus?
Lesser Occipital - C2
Greater Auricular - C2 and C3
Transverse Cervical - C2 and C3
Supraclavicular nerves - C3 and C4
What are the motor branches of the cervical plexus?
Nerve to ger and thyro
Ansa Cervicalis C1-C2
Phrenic Nerve C3-C5
Hypoglossal n. recieves some fibers from C1
What is A, B, and C?
A. descending cervicalis
B. Ansa cervicalis
C. Descending hypoglossus
Hypoglossal nerve supply which muscles?
Muscles of the tongue
The neck is a major crossroads where structures intersect coming and going from the ____, ______, and ______.
Head
Thorax
Upper limb
What two important endocrine glands are in the neck?
Thyroid and parathyroid
The sternomastid divides the neck into what?
Anterior and Posterior triangles
What are the borders of the posterior triangle?
SCM
Trapezius
Clavicle
What are the borders of the anterior triangle?
SCM
Mandible
Midline
The posterior triangle is divided into two smaller triangle by what?
By the Posterior Belly of the Omohyoid
What are the two smaller triangles that are within the Posterior triangle?
The occipital triangle
Subclavian triangle (also known as the supraclavicular triangle and omohyoid triangle)
The occipital triangle is crossed by the spinal root of _____ also known as the ______ nerve.
Spinal root of CN XI
“Carefree Nerve”
Why is CN XI vulnerable to injury while in the occipital triangle?
Because of its superficial course
What are the contents of the Occiptal triangle?
Accessory Lymph nodes
(Found along the nerve)
CN XI
What does the subclavian triangle contain?
3rd part of the subclavian artery
roots of brachial plexus
suprascapular artery
supraclavicular lymph nodes
What are the Sentinel nodes?
The left supraclavicular (Virchow’s) nodes
They signal deep onternal carcinomas
including from stomach, pancreas, uterus, and esophagous
What is a?
Subclavian Fossa
(also know as the supraclavicular fossa)
Artery and nerve found here
This vessel can be compressed against the 1st rib as it transverses the supraclavicular fossa?
Subclavian artery
What are the two things that transverse the subclavian fossa?
Subclavian artery
Brachial plexus
An injection of anesthetic above the middle of the clavicle into the subclavian fossa produces anesthesia and paralysis of the upper limb.
This is know as?
brachial plexus nerve block
this occurs at the middle third of the clavicle
What makes up the floor of the posterior triangles?
SCALENES
How does the Posterior scalene muscle differ from the middle and anterior?
Posterior attaches to othe second rib, where as the middle and anterior attach to the 1st rib
The space between the anterior and middle scalenes is known as the? What runs in it?
Scalene Triangle
The subclavian artery (2ndpart) & roots of the brachial plexus pass through the scalene triangle
Note that the subclavian vein is not a content of the subclavian triangle
Define Thoracic Outlet Syndrome
Acervical rib can grow into the scalene triangle, obstructing the artery. This can lead to compression of the brachial plexus.
Patient will develop sensorymotor symptoms
What is Scalene anticus syndrome?
like cervical rib syndrome but due to hypertonic scalene muscles
Pt will develop sensory motor symptoms
How does the Anterior scalene divide the subclavian artery?
It divides it into 3 parts
1 st part - proximal
2nd part - deep
3rd part - distal
What are the branches of the first part of the anterior scalene?
- Vertebral (major blood supply to brain stem. One of two arteries supply to the brain
- thyrocervicaltrunk (give rise to suprascapular and thyrocervical)
- internalthoracic (runs inside thoracic cage) – can be used in bypass
What is the path of the vertebral artery?
First part of subclavian artery
It ascends through transverse foramen of first 6 vertebra. When it reaches C1 is makes a S shaped turn and goes through foramen magnum -> joins other vertebral artery -> basilar artery
Whare is the vertebral artery most vulnerable?
Lateral to cervical spine just before FM , this is where the artery can becomes kinked off. Particularyif you have plaque -> when a person turns their head they get dizzy and can faint
THIS IS KNOW AS SYNCOPE
Which artery is the main blood supple to the brainstem?
Vertebral artery
Slide 32
Whats the location of the phrenic nerve in relation to the anterior scalene?
The phrenic nerve runs anteriorly on the anterior scalne.
This nerve originates from C3-C5 and provides GSE innervation to the diaphragm
The anterior triangle is subdivided into 4 triangles, what are they?
- Submental
- Submandibular
- Carotid
- Muscular
Submental Triangle
Boundaries
Contents
Boundaries
anterior bellies of digastric
hyoid bone
Content
submental nodes
origin of anterior jugular vein
What doe the submental nodes drain?
- central lower lip
- chin
- tip of tongue
- anterior floor of mouth
Submandibular triangle
Boundaries
Content
Content
Submandibular nodes (on top and behind gland)
Submandibular gland
facial artery
Lingual artery (posterior to the greater horn of the hyoid going to the tongue
CN XII (hypoglossal)
Boundaries
And and posterior belly of the digastic muscle
Mandible
What do the submandibular nodes drain?
Most of the oral and nasal cavity
What sometimes becomes enlarged and tender if a patient has mumps?
Submandibular gland
Carotid Triangle
Boundaries
Posterior belly of digastic
superior belly of onohyoid
sternocleidomastoid
Content
Carotid Sheath
carotid artery
vagus nerve (largest cranial nerve)
internal jusgular veins (located anterior-lateral)
Deep Cervical Lymph node - run w/ internal jugular v. (drain all structures of head and neck and found in/on carotid sheath.
What is the second major artery that suppies the brain?
Internal carotid
Contains the Carotid sinus (a dilation in the vessel that operates as a baroreceptor)
Also contains the Carotid Body (on the outside; it is a chemoreceptor that measures PCO2 and PO2)
This is an image of?
Carotid Endarterectomy
Removal of plaque from the Carotid artery
What is Horner’s Syndrome?
Disruption of sympathetic innervation of head (on one side)
Symptoms
- palpebral pseudoptosis (drooping eyelid)
- miosis (constricted pupil)
- enophthalmos(sinking of eye into orbit, appear)
- anhidrosis (dry skin due to lack of sympathetic innervation)
Where is the sympathetic chain and what are are it’s parts?
Located within or deep to the carotid sheath
Superior Cervical Ganglion - termination of sympathetic chain in the neck (always present)
Middle Cervical Ganglion (not always present
Inferior Cervical Ganglion
When it is joined together by the thoracic ganglion (right below it) it is known as the Stellate Ganglion - Star shaped
What is the teritory of the Sympathetic nervous system?
Sympathetic ganglion go from T1-L2
Preganglionic sympathetic fibers to the cervical ganglia
- originate from spinal cord levels T1-T5
- enter the sympathetic chain
- ascend to higher levels to synapse
After Synapse
Post ganglionic fiber
- leaves the chain via a gray communicating rami
- or forms plexuses around and travel with arteries to each their targets.
What nerve comes from the superior cervical ganglion and forms a plexus around the internal carotid artery?
Internal Carotid Nerve
Muscular triangle
Boundaries
midline
sternomastoid
omohyoid, superior belly
Content
Larynx
thyroid gland (isthmus is where the lobes join together)
parathryoid gland
Descent of the thyroid gland
The thyroid gland descend from the foramen cecum
(this is where the thyroid gland develops embryologically)
Descends in the adult; forming a duct as it descend. This is known as the thyroglossal duct. (accessory glandular thyroid tissue)
Cyst may develop along the duct and become infected
What is Goiter?
enlarged and/or overactive thyroid gland may cause goiter.
*may be removed by a “partial thyroidectomy” or radiation
Of the thyroid gland does not descend completely what does it form?
Lingual Thyroid Gland
Whare are the parathyroid glands located? And what is its function?
Typically, there are 2 parathyroid glands imbedded in each lobe of the thyroid gland
These glands secrete parathyroid hormone that elevates blood calcium levels
*note: position is variable, ranging from thyroid cartilage to the superior mediastinum
Why is Thyroidectomy a Hazardous procedure?
- Parathyroid gland may be located on the thryoid gland. Removal of the parathyroid gland results in a fall of blood calcium, tetany and death
- The external and reccurent laryngeal nerves are closely related to the thyroid gland. Damage to either can occur directly by surgical trauma or postsurgical edema -> this leads to dysphonia.
Where is Tracheostomy performed?
2nd and 3rd tracheal rings.
What is the major issue that can occur post techeostomy?
BLEEEDDDIIINNNGGG
- Isthmus must be remove to performe procedure. This part of the thyroid recieve major vasculariztion. Blood can go through opening in trachea and cause patient to choke
- Inferior thyroid vein runs anterior to the trachea. Must be reflected or ligated to prevent major bleeding
- (RARE) Thyroid ima artery can be a source of complication - goes right up to isthmus. May not always be present (Variation)
What are the 3 Zones of penetrating Neck Trauma?
Zone I - root of the neck; below cricoid cartilage
Zone II- middle of the neck; most exposed; between angle of teh jaw and cricoid cartilage (C6)
Zone III - above angle of the jaw
Zone I and II: greatest risk of morbidity and mortality becuase its difficult to get into these areas
Zone III: most commonly injured because it is so exposed
Major contents of Zone I (root of the neck)
A Viscera
1 trachea
2 esophagus
3 cupula and apex of lungs
B Glands
1 thyroid
2 parathyroid
C Nerves
1 vagus
2 recurrent laryngeal
3 phrenic
4 sympathetic chain
5 brachial plexus
D Blood vessels
1 common carotid
2 subclavian artery & vein
3 jugular veins
E Vertebral column
What is Pancoast Syndrome?
Thoracic Inlet Tumor
Tumor growing out of the root of the nect. Affects the Vagus nerve, phrenic nerve , brachial plexus, and sympathetic chain
It can cause
- Horner’ssyndrome (look at eyelid)
- parathesia and paresis of arm and hand (holding arm)
- superior vena cava syndrome (dilation of EJV)
- Dyspnea (diaphragm affected)
- Dysphonia (larynx nerve affected)
- Dysphagia (vagus)
- paralysis of ½ of the diaphragm
The cupula and apex of lungs extend where?
Extend into the root of the neck making it more vulnerable. Neck wounds may produce a pneumothorax
Deep fascia
- surrounds, supports & separates muscles, bones, arteries, nerves, glands, organs & etc.
- serves as an attachment for muscles
- facilitates the movement of muscles over other structures
- provides surgeon with a “bloodless” plane of dissection to isolate and remove structures
- may contain infection
- may provide a pathway for the spread of infections
What are the deep fascias of the neck?
- Investing layer of deep cervical - surrounds trapezoius and SCM
- Prevertebral fascia - surrounds interinsic muscles of the neck
- Carotis Sheath
- Pre-tracial fascia - surrounds traches, esophagous/pharynx, thyroid gland, and parathyroid gland
The space between the prevertebral fascia and the pretrachial fascia is known as the?
Retropharyngeal space
(can be filled w/ infection and blood)
Pretrachial fscia extends to _____ where the trachea ends.
Extends to T4.
Therefore the retropharyngeal space goes from the base of the skill to the thorax
infection that enter the retropharyngeal space can produce?
- Edema (and an abscess) that obstructs swallowing (dysphagia) and/or breathing.
- Infections may also enter the thorax producing mediastinitis (affects heart)
Side Note: A molor extraction is one thing that can cause infection.
