Neck Flashcards
1
Q
Superficial fascia of the neck
A
Contains platysma
2
Q
Deep cervical fascia
A
Found deep to the superficial fascia of the neck
Organised into several layers
- Investing fascia that surrounds the structures within the neck
- Prevertebral layer which surrounds vertebral column and deep muscles of the back
- Pretracheal layer which encloses viscera of neck
- Carotid sheath which recieve contribution from other fascial layers and sourround neurovascular bundle
3
Q
Investing layer fascia of the neck
A
Division of the deep cervical fascia
-Surrounds structures within the neck
Completely surrounds neck
Attaches posteriorly to ligamentum nuchae and spinous process of C7
Splits as it passes forwards enclosing trapezius, then reunites
Forms roof of posterior triangle
Splits again to enclose sternocleidomastoid and reunites
Attachments:
Superiorly: occipital protuberance and nuchal line
Laterally: mnastoid process and zygomatic arch
Inferiorly: spine of scapula, acromion, clavicle, manubrium
4
Q
Prevertebral fascia of the neck
A
Division of deep cervical fascia
-Surrounds vertebral column and deep muscles of the back
Cyclindrical layer of fascia
Surrounds prevertebral muscles, anterior, middle and posterior scalene muscles
And deep muscles of the back
Attachments:
- Posteriorly along ligamentum nuchae
- Superiorly: contiuous circular line to base of skull
- Anteriorly attached to anterior surface of vertebrak bodies CI - CVII
Extends to surround brachial plexus and subclavian artery to form axillary sheath
5
Q
Pretracheal fascia of the neck
A
Division of deep cervical fascia
-Encloses viscera of the neck
Surrounds trachea, oesophagus and thyroid gland
Begins superiorly at hyoid bone –> ends in upper thoracic cavity
Posteriorly, referred to as the buccopharyngeal fascia: separates the pharynx/oesophagus from the prevertebral layer
6
Q
Carotid sheaths
A
Division of deep cervical fascia
Recieve contribution from other fascia in neck
Surround neurovascular bundle on either side of the neck
- Common carotid artery
- Internal carotid artery
- Internal jugular vein
- Vagus nerve
7
Q
Axillary sheath
A
Continuation of prevertebral fascia
Containing subclavian arteyr and brachial plexus
8
Q
Fascial spaces of the neck
A
Pretracheal space
Retropharyngeal space
Third space
9
Q
Pretracheal space of the neck
A
Space between investing layer of cervical fascia covering the posterior surface of infrahyoid muscles
AND
Pretracheal fascia covering anterior surface of trachea and thyroid
space = neck and anterior superior mediastinum
10
Q
Retropharyngeal space of the neck
A
Space between the buccopharyngeal fascia on the posterior pharynx and oesophagus
AND
Prevertebral fascia on the anterior surface of the transverse process and bodies of cervical vertebrae
Space = base of skull to posterior mediastinum
11
Q
Third space of the neck
A
Space within the prevertabral later covering anterior processes of cervical vertebrae as the fascia divides into two laminae
Extends from base of skull down to diaphragm
12
Q
Formation of external jugular vein
A
Formed behind angle of mandible as posterior auricular and retromandibular vein join
13
Q
Formation and divisions of retromandibular vein
A
Superficial temporal vein and maxillary vein join in substance of parotid gland –> retromandibular vein
Then divides into anterior and posterior branches
Anterior branch of retromandibular vein joins the facial vein to form the common facial vein
Posterior branch of retromandibular vein joins posterior auricular vein to form EXTERNAL JUGULAR VEIN behnd angle of mandible
14
Q
Common facial vein
A
Formed by union of anterior branch of retromandibular vein and facial vein
Passes deep to drain into internal jugular vein
15
Q
Course of external jugular vein
A
Passes downwards in superficial fascia anteriorly to sternocleidomastoid crossing it diagonally
Joined by:
- Posterior extenral jugular vein
- Transverse cervical vein
- Suprascapular veins
At end of sternocleidomastoid, the external jugular passes posteriorly to pierce investing fascia, pass deep to clavicle, and join subvlavian vein
16
Q
Anterior jugular veins
A
Drain into subclavian vein after piercing investing layer of fascia
Often communicate via jugular venous arch around suprasternal notch
17
Q
Subdivisions of the anterior triangle of the neck
A
Submandibular triangle
Submental triangle
Muscular triangle
Carotid triangle
18
Q
Borders of the anterior triagnle of the neck
A
Laterally : Anterior border of sternocleidomastoid
Superiorly: border of mandible
Medially: midline
19
Q
Borders of the submandibular triangle
A
Superiorly: Inferior border of mandible
Inferiorly: Anterior and posterior bellies of digastric
20
Q
Borders of the submental triangle
A
Inferiorly: hyoid bone
Laterally: anterior belly of digastric
Medially: midline
21
Q
Borders of the muscular triangle
A
Superiorly: hyoid bone
Laterally: superior belly of omohyoid muscle and anterior border of distal sternocleidomastoid
Medially: midline
22
Q
Borders of the carotid triangle
A
Anteroinferiorly: Superior belly of omohyoid muscle
Superiorly: Stylohyoid muscle and posterior belly of digastric
Posteriorly: anterior border of sternocleidomastoid (middle)
23
Q
Suprahyoid muscles
A
Stylohoid
Digastric
Mylohyoid
Geniohyoid
ALL IN SUBMENTAL AND SUBMANDIBUALR TRIANGLE
24
Q
Infrahyoid muscles
A
Omohyoid
Sternohyoid
Thyrohyoid
SternoTHYROID
ALL IN MUSCULAR COMPARTMENT
25
Innervation of stylphyoid muscle
Innervated by the faical nerve
O: Base of styloid process
I: Lateral area of body hyoid
F: Pulls hyoid posterosuperior
26
Innervation of digastric muscle
Anterior belly: Mylohyoid nerve from inferior alveolar branch of mandibular branch of trigeminal V3
O: Digastric fossa on inside of lower mandible
I: Attachment tendon
F: Opens mouth, raises hyoid
Posterior belly: Facial nerve VII
O: Mastoid notch on medial mastoid
I: Attachment tendon
F: Pulls hyoid back superoposterior
27
Innervation of mylohyoid
Innervated by the mylohyoid nerve from alveolar branch of the mandibular division of the trigmeinal nerve V3
O: Myohyoid line of mandinle
I: Body of hyoid and midline convergence
F: Support elevation of floor of mouth + elevation of hyoid
28
Innervation of geniohyoid
Innervated by C1 anterior ramus, carried in hypoglossal nerve XII
O: Inferior mental spine on inner surface of manidble
I: Anterior surface of body of hyioid
F: Pulls mandible downards, elevates hyoid
29
Innervation of sternohyoid
Innervated by anterior rami of C1 - C3 ansa cervicalis
O: Posterior aspect of sternoclavicular joint and manubrium
I: Body of hyoid bone medial to omohyoid muscle
F: Depresses hyoid bone after swallowing
30
Innervation of omohyoid
Innervated by anterior rami of C1 - C3 ansa cervicalis
O: Superior border of scapula medial to suprascapular notch
I: Lower border of body of hyoid lateral to sternohyoid attachment
F: Depresses hyoid
31
Innervation of thyrohyoid
Innervated by anterior rami of C1 carried along hypoglossus nerve XII
O: Oblique line of thyroid cartilage
I: Greater horn and adjacent body of hyoid
F: Depresses hyoid or raises larynx
32
Innervation of sternothyroid
Innervated by anterior rami of C1 - C3 ansa cervicalis
O: Posterior surface of manubrium
I: Oblique line of lamina of thyroid cartilage
F: Draws larynx downwards
33
Innervation of carotid sinus
Glossopharyngeal nerve IX
= changes in blood pressure
34
Innnervation of carotid body
Glossopharyngeal nerve XI
AND
Vagus nerve X
= changes in blood chemistry and PO2
35
Branches of the external carotid artery
Superior thyroid artery
Ascending pharyngeal artery
Lingual artery
Facial artery
Occipital artery
Posterior auricular artery
Superficial temporal artery
Maxillary artery
36
Superior thyroid artery
Branch of external carotid artery
Supplies:
- Thyrohyoid muscle
- Larynx
- Sternocleidomastoid
- Cricothyroid muscle
-Thyroid gland
37
Ascending pharyngeal artery
Branch of external carotid artery
Supplies:
- Pharyngeal constrictors
- Stylopharyngeus muscle
- Palate
- Tonsil
- Pharyngotympanic tube
- Posterior cavity meninges
38
Veins draining into internal jugular veins
(Inferior petrosal sinus)
Facial vein
Lingual vein
Pharyngeal vein
Occipital vein
Superior thyroid vein
Middle thyroid vein
39
Facial nerve innervates to muscle in anterior triangle
Stylohyoid
Posterior belly digastric
(+platysma)
40
Stylohyoid nerve
Facial nerve
41
Posterior belly of digastric nerve
Facial nerve
42
Glossopharyngeal innervates structures in anterior triangle
Stylopharyngeus muscle
Carotid body and sinus
Sensory branch to pharynx
43
Path of glossopharyngeal IX in anterior triangle
Exits cranial cavity through jugular Forman
Between internal carotid and internal jugular vein
Descends deep to styloid process
Passes in between internal carotid and internal jugular towards stylopharyngeus
44
Orientation of vagus nerve in carotid sheath
Medial to internal jugular vein
Posterior to internal carotid artery
45
Path of the accessory nerve
Most posterior nerve leaving jugular foramen
Begins descent medial to internal jugular vein
Then passes over lateral surface of internal jugular vein and pierces sternocleidomastoid
46
Branches of vagus nerve in anterior triangle
Motor branch to pharynx
Branch to carotid body
Superior laryngeal nerve --> divides into external and internal laryngeal nerves
47
Path of hypoglossus in anterior neck
No branches
Exits cranial cavity through hypoglossal canal
Medial to internal jugular
Then passes outwards and then hooks around occipital artery
Continues deep to posterior belly of digastric
Passes over surface of hyoglossus muscle
48
Transverse cervical nerve
C2 - C3
Emerges from border of sternocleidomastoid
Cutaneous innervation to anterior neck
49
Ansa cervicalis
Loop of nerve C1 - C3
Innervate strap muscles
C1 joins hypoglossus nerve XII as it leaves skull through hypoglossal canal
Superior root: As hypoglossus passes forward across internal and external carotid arteries --> fibres pass out
- -> descend between internal jugular and common carotid
- -> innervates superior belly of omohyoid + sternohyoid + sternothyroid
C2-C3 branches complete loop
=inferior root
50
Superior root of ansa cervicalis
C1 and hypoglossus
51
Inferior root of ansa cervicalis
C2 - C3
innervates inferior belly of omohyoid + lower sternohyoid + sternothyroid
52
Location of isthmus
Covers 2nd - 3rd TRACHEAL rings
53
Pyramidal lobe of thyroid
Vairant in which lobe extnds up from thyroid glan din thyroglossal duct
54
Lingual thyroid
Variant in which there is a functional thyroid lobe at base of tongue
55
Superior thyroid artery
Branch of external carotid artery
Descends passing along lateral margin of thyrohyoid muscle to superior pole of thyroid
Divides into anterior and posterior superior thyroid branches
56
Anterior glandular branch of superior thyroid artery
Passes along superior border of thyroid gland and anastomoses with its paired artery across the isthmus
57
Posterior glandular branch of superior thyroid artery
Passes posteriorly to thyroid and may anastomose with inferior thyroid artery
58
Inferior thyroid artery
Branch of thyrocervical trunk, brancch of first part of subclavian
Ascends on medial margin of anterior scalene muscle
Passes posteriorly to carotid sheath
At inferior pole of thyroid divides into inferior and ascening branches
59
Inferior branch of inferior thyroid artery
Superior branch of inferior thyroid artery, which in turn is a branch of the thyrocervical trunk of the first part of the subclavian artery
Supplies lower thyroid and anastomoses with inferior glandular branch of superior thyroid artery
60
Ascending branch of inferior thyroid artery
Branch of inferior thyroid artery, which in turn is a branch of the thyrocervical trunk of the first part of the subclavian artery
Supplies parathyroid glands
61
Thyroid ima artery
Variant arteyr in 10% of population
Branch of brachiocephalic trunk or arch of aorta
Ascends on anterior surface of trachae to supply thyroid
62
Venous drainage of thyroid
3 veins
Superior thyroid vein: drains upper 1/2
--> drains to internal jugular vein
Middle and inferior thyroid veins: drain lower 1/2
Middle vein --> drains to internal jugular vein
Inferior vein --> drains braciocephalic vein
63
Recurrent laryngeal nerves and thyroid
Recurrent laryngeal nerves ascend in groove between trachea and oesophagus
Pass under posteromedial surface of lateral lobes of thyroid gland and enter larynx
--> pass through lower margin of inferior pharyngeal constrictor
64
Posterior triangle boundaries
Anterior: posterior edge of sternocleidomastoid
Posterior: anterior edge of trapezius
Inferior: middle third of clavicle
Superior / apical: posterior to mastoid process where attachments of trapezius and sternocleidomastoid merge
Roof: investing layer of cervical fascia
Floor: pre-vertebral fascia covering splenius capitus, levator scapulae, posterior, middle and anterior scalene muscle
65
Division of posterior triangle of neck
Omohyoid passes from posterior triangle --> anterior triangle
Divides posterior triangle with inferior belly:
- Above = occipital triangle
- Below = omoclavicular or subclavian
66
Innervation of omohyoid
Ansa cervicalis, anterior rami of C1 - C3
O: Superior border of the scapula, medial to sc
67
Dorsal scapular artery
Only branch of the third part of the subclavian artery
Branches at base of posterior triangle of neck
Passes to superior angle of scapula
Passes down medial edge of scapula
Supplies rhomboid muscles
68
Transverse cervical artery
Middle branch of the thyrocervical trunk of first part of subclavian artery
Passes anterior to anterior scalene muscle into base of posterior triangle
Passes to trapezius, divides:
- Superficial: supplies trapezius
- Deep: continues to supply rhomboids
69
Suprascapular artery
Branch of thyrocervical trunk of first part of subclavian artery
Passes into base of posterior triangle
Passes over superior transverse scapular ligament
Supplies muscles on posterior scapula
70
Course of accessory nerve in posterior triangle
Accessory nerve XI exits cranial cavity through the jugular foramen
Descends through the neck in a posterior direction --> sternocleidomastoid
--> Passes deep or through sternocleidomastoid innervating it
Continues to descend obliquely in posterior triangle to reach trapezius
--> continues on deep surface of trapezius, innervating it
Superficial course of accessory nerve within the investing layer of the cervical fascia as it passes in posterior triangle between sternocleidomastoid to trapezius leaves it susceptible to injury
71
Formation of cervical plexus
Anterior rami of C2 - C4
+/- contribution from C1
Forms in muscles making up the floor of the posterior triangle within PREVERTEBRAL fascia
- Muscular (deep) branches
- -> Superior root of ansa cervicals
- ->Inferior root of ansa cervicalis
- -> Phrenic nerve (needs contribution from C5)
- Superficial (sensory) branches
- -> Lesser occipital nerve
- ->Great auricular nerve
- ->Transverse cervical nerve
- ->Supraclavicular nerve
72
Motor branches of cervical plexus
- -> Superior root of ansa cervicals
- ->Inferior root of ansa cervicalis
- -> Phrenic nerve (needs contribution from C5)
73
Sensory branches of cervical plexus
Lesser occipital nerve
- C2
- Skin of neck and scalp posterior to ear
Great auricular nerve
- C2 and C3
- Skin to parotid region, ear and mastoid region
Transverse cervical nerve
- C2 and C3
- Lateral and anterior neck
Supraclavicular nerve
- C3 and C4
- Skin over clavicle and down to rib II
74
Lesser occipital nerve
- C2
| - Skin of neck and scalp posterior to ear
75
Great auricular nerve
- C2 and C3
| - Skin to parotid region, ear and mastoid region
76
Transverse cervical nerve
- C2 and C3
| - Lateral and anterior neck
77
Supraclavicular nerve
- C3 and C4
| - Skin over clavicle and down to rib II
78
Vertebral artery
First branch of subclavian artery
Branches medial to anterior scalene
Ascends and passes through foramen of transverse process CVI
At C1, turns and passes over posterior arch of C1 --> foramen magnum
79
Thyrocervical trunk
Second branch of subclavian artery
Arises from first part, medial to anterior scalene
Divided into three branches:
- Superior: Inferior thyroid
- Middle: Transverse cervical
- Inferior: Suprascapular
80
Ascending cervical artery
Branch of the inferior thyroid artery, a branch of the thyrocervical trunk
As the inferior thyroid artery turns medially, crossing posteriorly to carotid sheath --> branches ascending cervical artery
Ascending cervical artery ascends anterior to prevertebral muscle
81
Internal thoracic artery
Third branch of the subclavian artery
Branches from inferior edge and descends
Passes posterior to clavicle
Enters thoracic cavity anterior to transversus thoracis muscle
82
Costovcervical trunk
Final branch of subclavian artery
Left side: arises first part of subclavian medial to anterior scalene
Right side: arises from second part of subclavian artery
Then ascends and passes posteriorly over dome pleural cavity
--> behind anterior scalene
Divides into two branches:
- deep cervical artery
- supreme intercostal artery
83
Deep cervical artery
Branch of the costocervical trunk after it passes posteriorly to anterior scalene
Ascends in back of neck and anastomoses with descending branch of occipital artery
84
Supreme intercostal artery
Branch of the costocervical trunk after it passes posteriorly to anterior scalene
Descends, anterior to rib I
--> forms posterior intercostal arteries for intercostal spaces I and II
85
Only 1 tributary to subclavian vein
External jugular vein
86
Course of the phrenic nerve in the neck
Arise from the cervical plexus (C2 - C4) and then additional C5
Passes around upper lateral border of anterior scalene
Descends on anterior surface of anterior scalene within the prevertebral layer of cervical fascia
Leaves lower end anterior scalene, passes between subclavian vein and artery
Enters thorax
87
Course of vagus nerve in the neck
Vagus nerve descends through the neck in the carotid sheath
Posterior (and in-between) common carotid and internal jugular vein
Passes anterior to subclavian artery, in between subclavian vein and artery
88
Right recurrent laryngeal nerve
Arises as the right vagus nerve passes in front of subclavian artery
It loops around the subclavian artery and ascends in the neck in a groove between trachea and oesophagus
--> larynx
89
Left recurrent laryngeal nerve
Arises as the left vagus nerve crosses the arch of the aorta in the superior mediastinum
Loops below and behind the arch of the aorta
Ascends beside the trachea --> larynx
90
Cervical part of the sympathetic trunk
Anterior to longus colli and longus capitis muscle
Posterior to common carotid artery in the carotid sheath
Connected to each spinal nerve by grey ramus communicans
- there are no white rami communicantes in the cervical region
NOTE: grey ramus commincuans carry post-ganglionic sympathetically fibres
Hence, there are no pre-ganglionic fibres leaving the cervical region and therefore no white rami communicantes
91
Ganglia of cervical sympathetic trunk
Superior cervical ganglion: level of C1 - C2
Middle cervical ganglion: level of C6
Inferior cervical ganglion: combined with first thoracic ganglion to firm cervicothoracic ganglion (stellate ganglion)
92
Superior cervical ganglion
Anatomically lies adjacent to C1 - C2
Branches to:
- Internal and external carotid arteries
- Cervical spinal nerve C1-C4 through grey rami communicantes
- Pharynx
- Superior cardiac nerves
93
Middle cervical ganglion
Anatomically adjacent to C6
Branches:
- Cervical spinal nerves C5 - C6 through grey rami communicantes
- Middle cardiac nerves
94
Inferior cervical ganglion
Combines with first throacic ganglion to form cervicothoracic ganglion
=Stellate ganglion
Anterior to neck of 1st rib and transverse process of C7
Posterior to first section of subclavian artery + origin of vertebral artery
Branches
- Spinal nerve C7 - T 1 through grey rami communicants
- Vertebral artery - forming plexus
- Inferior cardiac nerves
95
Thoracic duct
Major lymphatic channel
Begins in abdomen
Passes superiorly
- Thoracic aorta on left
- Azygous vein on right
- Oesophagus anteriorly
At T5, thoracic duct passes to the LEFT
Continues to ascend left of the oesophagus
Passes laterally posterior to carotid sheath turns inferiorly
IN FRONT OF thyrocervical trunk, phrenic nerve and vertebral artery
Terminates in junction between left internal jugular and left subclavian vein
96
Thoracic duct terminates...
Terminates in junction between left internal jugular vein
AND
Left subclavian vein
97
Tributaries to thoracic duct
Left jugular trunk
Left subclavian trunk
Left bronchomediastinal trunk
98
Pharyngeal raphe
Connect tissue midline that marks the fusion of both sides of the phrarynx
Extends from pharyngeal tubercle on base of skull to C6 where raphe blends with posterior wall of oesophagus
99
Pterygomandibular raphe
Linear cord-like connective tissue
Ptreygoid hammulus --> posterior mandible
Joins superior constrictior / lateral pharyngeal wall with buccinator muscle
100
Points of attachment of lateral pharyngeal wall
1. pterygomandibular raphe
2. lower stylohyoid ligament + hyoid bone
3. superior and inferior tubercle of thyroid cartilage extending onto cricoid cartilage
101
Innervation of superior constrictor of pharynx
Innervated by the pharyngeal branch of vagus nerve
O: pharyngeal raphe
I: pterygomandibular rapge and adjacent bone on mandible and pterygoid hammulus
F: constricts pharynx, circular muscle fibres
102
Innervation of middle constrictor of pharynx
Innervated by the pharyngeal branch of vagus nerve
O: pharyngeal raphe
I: upper margin of greater horn of hyoid bone and adjacent margins of lesser horn and stylohoid ligament
F: constricts pharynx, circular muscle fibres
103
Innervation of lower constrictor of pharynx
Innervated by the pharyngeal branch of vagus nerve
O: pharyngeal raphe
I: cricoid cartilage, oblique line of thyroid cartilage, and ligament that spans superior inferior tubercle of thyroid cartilage
F: constricts pharynx, circular muscle fibres
104
Palatopharyngeal sphincter
Band of muscle originates from anterolateral surface of soft palate
Circles inner aspect of pharyngeal wall and blends with superior constrictor
Seals pharyngeal isthmus between naropharynx and oropharynx
105
Innervation of stylopharyngeus
Innervated by glossopharyngeal nerve IX
O: medial side of styloid process
I: descends between upper and middle constrictors --> pharyngeal wall
F: elevation of pharynx
106
Innervation of salplingopharyngeus
Innervated by vagus nerve X
O: inferior aspect of pharyngeal end of pharyngotympanic tube
I: pharyngeal wall
F: elevates pharynx
107
Innervation of palatopharyngeus
Innervated by vagus nerve X
O: upper surface of palatine aponeurosis
I: pharyngeal wall
Forms palatopharyngeal arch
F: elevates pharynx and closes oeopharyngeal isthmus
108
Buccopharyngeal fascia
Thin layer of fascia that coat soutside of muscular wall of pharynx
Component of pretracheal layer of cervical fascia
109
Pharyngobasilar fascia
Thick layer of fascia that lines innfer surface of pharynx
110
Pharyngeal fascia
Buccopharyngeal fascia
- Thin
- Outside
Pharyngobasilar fascia
- Thick
- Inside
111
Reinforcement of superior wall of pharynx
Superior constrictor leaves large deficiency superiorly
This is reinforced with fascia (pharyngobasilar) and muscles of the soft palate
-levator veli palatini
112
Triangular aperture of pharyngeal wall
Deficiency between:
- superior constrictor
- middle cosntrictor
- posterior border of mylohyoid
-stylopharyngeus muscle passes through to inset on pharynx
Structures passing through gap to enter larynx from pharynx:
- internal layrngeal vessels
- nerve to aperture in thyrohyoid membrane
- recurrent laryngeal nerve
113
Pharyngeal tonsils
Previosuly described when enlarged as adenoids
Located at mucosa covering roof of nasopharynx
-enlargement may occlude breathing
114
Torus levatorius
Broad fold /elevation emerging from base of opening of pharyngotympanic tube
-> continues medially on upper surface of soft palate
Fold overlies levator veli palatinin
115
Torus tubarius
Elevation / bulde from posterior rim of pharyngotympanic tube
Pharyngeal recess formed behind the bulge
116
Valleculae
Mucosal pouches
Located anteriorly, one on each side of the midline in the laryngopharynx
--> form base of tongue to epiglottis
117
Piriform fossae
Channels that direct solids and liquids from oral cavity around raised laryngeal inlet into oesophagu s
Located between central part of larynx and lateral lamina of thyroid certilage
118
Location of palatine tonsils
Each side of oropharynx between palatglossal arch and palatopharyngeal arch
Just posterior to oropharyngeal isthmus
119
Lingual tonsil
Lymphoid nodules on posterior 1/3 of tongue
120
Arterial supply to pharynx
Ascending pharyngeal artery, branch of external carotid artery
Ascending palatine and tonilsar branches of facial artery
Maxillary and lingual arteries
121
Blood supply to palatine tonsil
Tonsilar branch of facial artery
--> penetrates superior constrictor
122
Lymphatic drainage of the palatine tonsil
Drains into jugulodigastric nodes
123
Components of the pharyngeal plexus
Pharyngeal branch of vagus nerve X
External laryngeal nerve branches, from superior laryngeal nerve of the vagus nerve X
Pharyngeal branches of the glossopharyngeal nerve IX
124
Motor supply to the pharynx
All innervated by vagus nerve
with exception of stylopharyngeal muscles which is innervated by glossopharyngeal nerve
125
Pharyngeal branch of the vagus nerve
Originates form inferior ganglion of vagus nerve
| above origin of superior latryngeal nerve
126
Sensory innervation to nasopharynx
Pharyngeal branch of maxillary nerve V2 of trigmeinal nerve
Originated in pterygopalatine fossa --> palatovaginal canal in sphenoid --> roof of pharynx
127
Sensory innervation to oropharynx
Innervated by glossopharyngeus IX via pharyngeal plexus
128
Sensory innervation to laryngopharynx
Innervated by vagus nerve X via its internal branch of the superior laryngeal nerve
129
Path of glossopharyngeus nerve in pharynx
Exits cranial cavity through jugular foramen
Descends on posterior aspect of stylopharyngeus
Passes on lateral aspect of stylopharyngeus --> passes anteriorly through gap betweeen superior and middle constrictors
As it passes under free edge of superior constrictor, lies inferior to palatine tonsil
Here it branches, sensory arm for gag reflex and palatine tonsil
130
Carilages of the larynx
Unpaired:
- cricoid
- thyroid
- epiglottis
Paired:
- arytenoid
- corniculate
- cuneiform
131
Laryngeal prominence
Superior margin of fusion of broad laminae of thyroid cartilage
Acute angle 90 in males = adam's apple
Broaded angle 120 in females
132
Lateral thyroid ligament
Posterior end of greater horn of hyoid bone --> superior horn of thyroid cartilage
133
Aperture in lateral thyrohyoid memrbane
Superior laryngeal artery and internal branch of superior laryngeal nerve pass through
134
Hypo-epiglottic ligament
Midline of epiglottis --> body of hyoid
135
Cricothyroid ligament
Arch of cricoid cartilage --> thyroid cartilage anteriorly and arytenoid cartilages vocal processes
136
Quadrangular membrane
Lateral margin of epiglottis --> anterolateral surface of arytenoid cartilages
Forms vestibular ligament (false cords)
137
Surgical approach to large goitre
Ansa cervicalis runs in lower 1/2 of strap muscles
Strap muscles ar edivided in upper 1/2 to avodi ansa cervicalis
138
Level of division of common carotid
At upper border of throid cartilage
= C3
139
Structures in between internal and external carotid
Stylopharyngeus
Styloid prcoess
Glossopharyngeal nerve
Pharyngeal branch of vagus nerve
140
Relative position of internal jugular vein
Formed by continuation of sigmoid sinus
Initally lies posterior to internal carotid
As it descends, it lies lateral to internal carotid and common carotid artery
Contained within the carotid sheath, which is thinner
over the vein, allowing it to distend
The deep cervical chain of lymph nodes is found
along the internal jugular vein ---> In block dissection of the neck, the internal jugular vein is removed to facilitate removal of the nodes
141
Internal jugular vein cannulation
High approach: C6
-palpated lateral to common carotid at anterior border of sternocleidomatoid
Low approach
-need inserted near apex of triangular gap between the sternal and clavicular heads of sternocleidomastoid
142
Arterial supply to thyroid
Superior thyroid artery: branch of external carotid
-related close to external branch of superior laryngeal nerve clos eto gland
Inferior thyroid artery: branch of thyrocervical trunk (1st part of subclavian)
-related close to recurrent laryngeal nere close to gland
143
Venous drainage of thyroid gland
Superior thyroid vein --> internal jugular vein
Middle thyoid vein --> internal jugular vein
Inferior thyoird vein --> brachiocephalic vein
144
Incision for thyroidectomy
Transverse incision in skin crease two fingers breadth
ABOVE
supersternal notch
145
Structures encountered during thyroidectomy
Skin
Platysma
Investing fascia: opended longitudinally between strap muscle and anterior jugular vein
Strap muscles, which may be divided in their upper half to preserve their nerve supply from ansa cervicalis
Pretracheal fascia
--> exposes thyroid gland
Care must be taken in dividing the:
Superior thyroid artery - divide close to the gland, to avoid the external branch of the superior laryngeal nerve
Inferior thyroid artery - divide far away from the gland, to avoid the recurrent laryngeal nerve
146
Position of superior parathyroid glands
Lie at the middle of the posterior border of the lobe
of the thyroid above the level at which the inferior
thyroid artery crosses the recurrent laryngeal nerve.
147
Posterior cricoarytenoid
Abducts cords
Cricothyroid tenses the vocal cord
All other muscles adduct the cords, i.e. sphincter action
148
Cricothyoird
Tenses cords
Posterior cricoarytenoid abducts cords
All other muscles adduct the cords, i.e. sphincter action
149
Blood supply to larynx
Superior laryngeal artery
Inferior laryngeal artery
Accompany the superior laryngeal nerve and the recurrent laryngeal nerves, respectively
150
Lymphatic drainage of the larynx
Above the vocal cords to the upper deep cervical nodes
Below the vocal cords to the lower deep cervical nodes
Vocal cords separate the two areas of drainage anteriorly but posteriorly there is cross-communication.
151
Nerve supply to larynx
Superior laryngeal nerve
- branch of vagus nerve
- divides into internal and external branches
- --> internal branch pierces thyrohyoid membrane and supplies sensory innervation above vocal cords
- --> etxenral branch supplies cricothyroid muscle
Recurrent laryngeal nerve
- branch of vagus nerve
- -> supplies all muscle of larynx except cricothyroid
- -> supplies sensory innervation to mucosa below vocal cords
152
Nerve injury during thyroidectomy
Superior laryngeal nerve --> external laryngeal nerve
- close to superior thyroid artery
- ligation of superior thyrid close to gland minimises risk
Recurrent laryngeal nerve
- -> lies close to inferior thyroid artery
- this should be ligated well laterally to avoid damage to recurrent laryngeal
153
Palatine arches
Anterior pillar = palatoglossal arch
--> formed by palatglossal muscle
Posterior pillar = palatopharyngeal arch
--> palatopharyngeus muscle
154
Pharyngobasilar fascia
Lines inner surface of superior constrictor and forms capsule of palatine tonsil
155
Paratonsilar vein
= troublespme bleeding during tonsillectomy
Paratonsilar vein extends from soft palate to lie on lateral surface of tonsil --> then pierces superior constrictor
Tonsillectomy involves removal of the tonsil and the
fascial capsule separating it from the loose areolar
tissue clothing the superior constrictor.
156
Lymphatic drainage of palatine tonsil
Jugular digastric lymph nodes
behind angle of mandible
157
Blood supply to palatine tonsil
Tonsillar branch of facial artery
-> pierces superior constrictor at lower pole of tonsil
Additional branches from: lingual, ascending pharyngeal and ascending palatine arteries
158
Piriform fossa
= common place for foreign bodies lodged
Good lymphatic drianage --> fast tumour seeding to depp cervicla nodes
159
Nasopharynx epithelium
Pseudostratified columnar ciliated
Rest of phayrnx has stratified squamous
160
Killian’s dehiscence
Posterior midline: thyropharyngeus and cricopharyngeus
161
Sensory innervation to the pharynx
Nasopharynx: maxillary division of trigeminal nerve
Orophaynx: glossopharyngeal nerve
Laryngopharynx: internal branch of superior laryngeal nerve (of vagus nerve)
162
Contents of posterior triangle of neck
3rd part of subclavian artery
Transverse cervical artery
Suprascapular artery
Occipital artery
External jugular vein: courses in the superficial fascia obliquely
SPINAL ACCESSORY NERVE
163
Course of spinal accessory nerve in the posterior triangle
Exits the cranial cavity through jugular foramen
passes eep to sternocleidomastoid (at this point enters posterior triangle)
Lies superficially embedded in deep fascia roof
Enters under surface of trapezius
Supplies: sternocleidomastoid and trapezius
It lies on the levator scapulae.
164
Biopsy of node in posterior triangle
=accessory nerve injury
--> inability to shrug shoulder on affected side
165
Superficial branches of cervical plexus
Lesser occipital nerve
Greater auricular nerve
Transverse cervical nerve
Supraclavicular nerve
166
Deep branches of cervical plexus
Supply:
- prevertebral muscles
- infrahyoid muscles - ansa cervicalis.
- diaphrgam -phrenic nerve
167
Ansa cervicalis
Loop formed anterior to carotid sheath
Branch of C1 after it has joined with hypoglossal nerve
AND
Branch from union of C2 and C3 nerve roots
168
Right phrenic nerve
Anterior to vagus nerve at mediastinum
Descends on lateral side of SVC
--> down the right surface of the pericardium to pierce the diaphragm in company with the inferior vena cava
169
Left phrenic nerve
In superior mediastinum: lies between left subclavian artery posteriorly and common carotid anteriorly
Crosses left side of arch of aorta to pass anteriorly to root of lung
Travels down on the left surface of the pericardium
to pierce the diaphragm
170
Sibson's fascia
Suprapleural membrane
Attached to inner border of 1st rib and transverse process of C6
Prevents lung rising further into neck during inspiration
Structure lieing on it:
- Subclavian artery
- Subclavian vein
- Brachial plexus
171
Branches of subclavian artery
Vertebral artery
Internal mammary (thoracic) artery
Thyrocervical trunk
Costocervical trunk
172
Thoracic duct
Carries lymph from the whole body except right hemithorax, arm, head and neck
Commences at costerna chyli - between abdominal aorta and rigth crus
Passes through aortic opening in diapgrahm and T12
Ascends behind oesophagus up to T5
-at T5 it inclines to the LEFT
At root of neck, arches laterally
-lying between carotid sheath and vertebral artery
Enters the junction between internal jugular and subclavian vein
173
Location of stellage ganglion
Lies anterior to neck of 1st rib
174
Vertical chain deep cervical nodes
Lies in fascia of carotid sheath
Can be divided:
-superior deep cervical nodes
--> tonsils, tongue (posterior 1/3rd)
=posterior belly of digastric crosses internal jugular vein
- inferior deep cervical nodes
--> anterior 2/3rd tongue, oral cavity, trachea, oesophagus, thyroid gland
=omohyoid cross internal jugular vein
175
Block dissection of the neck
Block dissection of the neck extends from the mandible
above to the clavicle below and the midline anteriorly
to the anterior border of trapezius posteriorly
= Leaving only the carotid arteries, the vagus nerve, the sympathetic trunks, and the lingual and hypoglossal nerves
All structures from platysma to pretracheal fascia
are removed
Sternocleidomastoid, posterior belly of digastric and
omohyoid are all removed, along with the internal
jugular and external jugular veins, submandibular
gland and lower part of the parotid gland.
The accessory nerve, to which lymph nodes are
related in the posterior triangle, is also sacrificed.
176
Foramen transversarium
Transmits:
- vertebral artery (NOT C7)
- vertebral vein
- sympathetic fibres
177
C1 and C7
Don't have bifid spines
178
Movements around C1-C2
Nodding (agreement) and lateral flexion occur
at the atlanto-occipital joint
Rotation of the skull (disagreement) occurs at
the atlantoaxial joint
179
Paracentral slipped disc L4 / L5
Impinges L5
- -> weakness of dorsiflexion
- -> weakness bog toe extension
Numbness over:
- lower lateral leg
- medial side of foot
180
Paracentral slipped disc L5 / S1
Impinges S1
- -> absent / weak ankle jerk reflex
- -> weakness foot eversion
Numbness over lateral foot
