Neck - Anterior Triangle, Deep NV Flashcards
Borders of the anterior triangle of the neck?
Anterior - midline of the neck
Posterior - anterior border of SCM
Superior - inferior border of mandible
Floor - pharynx, larynx and thyroid
What are the 4 sub-triangles found in the anterior triangle?
Which one is unpaired?
Submental (unpaired)
Submandibular
Carotid
Muscular
What are the borders of the submental triangle?
Lateral - anterior bellies of digastric muscles
Base - body of hyoid bone
Apex - symphysis of mandible
Floor - mylohyoid muscles
What is found in the submental triangle?
submental lymph nodes
What are the boundaries of the submandibular triangle?
Anterior/Posterior - A & P bellies of the digastric muscle
Superior - inferior border of mandible
Floor - mylohyoid and hyoglossus muscles, middle pharyngeal constrictor
What is found in the submandibular triangle?
Submandibular gland
Hypoglossal nerve (CN XII)
Nerve to mylohoid (branch of trigeminal CN V)
Facial artery (*deep to submandibular and the posterior belly of digastric)
Stylohyoid muscle
What is the relationship with the facial artery and vein found in the submandibular triangle?
Facial artery is deep to the submandibular gland
Facial vein is superficial to the submandibular gland
What are the boundaries of the carotid triangle?
Anterior - superior belly of omohyoid
Posterior - anterior border of SCM
Superior - posterior belly of digastric
Floor - ?
What is found in the carotid triangle?
Common, external, and internal carotid arteries
Carotid sinus (dilation of proximal ICA)
Carotid body
IJV
Vagus nerve (CN X)
Ansa cervicalis - motor to infrahyoid muscles (except thyrohyoid)
What are the boundaries of the muscular triangle of the anterior neck?
Medial - midline of the neck
Superolateral - superior belly of omohyoid
Inferolateral - anterior border of SCM
What is found in the muscular triangle of the neck?
Infrahyoid muscles
Neck viscera
Functions of the suprahyoid muscles?
Superior to the hyoid
Attach hyoid to cranium and elevate hyoid and larynx
Form floor of mouth and support the tongue
What are the suprahyoid muscles?
Mylohyoid
Geniohyoid
Stylohyoid
Digastric
Origin and insertion of mylohyoid?
O - inner mandibular body
I - body of hyoid, midline
What innervates the mylohyoid?
Nerve to mylohyoid (branch of trigeminal nerve - CN V)
Where is the geniohyoid muscle found in relation to mylohyoid?
Deep to mylohyoid
Origin and insertion of geniohyoid?
O - inner mandiular apex
I - body of hyoid
What innervates the geniohyoid muscle?
Ventral ramus of C1
Origin and insertion of stylohyoid?
O - styloid process
I - body of hyoid
Relationship of stylohyoid to digastric muscle?
Wraps around posterior digastric
What innervates the stylohyoid?
Stylohyoid branch of facial nerve - CN VII
The digastric muscle is made of up _______ and _______ bellies and is jointed by ________________.
Anterior and posterior
intermediate tendon
Why do the digastric bellies have different origins and nerve innervations?
Embryologically, they were separate
Origin(s) and insertion of the digastric muscle?
O - inferior mandibular apex (anterior); mastoid process (posterior)
I - sling at body of hyoid
What allows the intermediate tendon to slide?
The sling found at the body of the hyoid (the insertion of the digastric muscle)
What nerve(s) innervate the digastric muscle?
Anterior - nerve to mylohyoid (branch of CN V)
Posterior - digastric branch of CN VII
The infrahyoid muscles are also known as “___” muscles.
Strap muscles
What do the infrahyoid muscles do?
Attach hyoid to manubrium, clavical and scapula
Depress hyoid and larynx
What are the infrahyoid muscles?
Sternohyoid
Omohyoid
Sternothyroid
Thyrohyoid
Origin and insertion for sternohyoid?
O - manubrium
I - body of hyoid
What innervates the sternohyoid muscle?
Ansa cervicalis
Omohyoid has ________ and _____ bellies that are joined by ___________
Superior and inferior
Intermediate tendon
Origin and insertion of omohyoid muscle?
O - body of hyoid (superior); superior border of scapula (inferior)
I - sling arising from clavicle
What nerve innervates omohyoid?
Ansa cervicalis
Origin and insertion of sternothyroid?
O - manubrium
I - thyroid cartilage
What nerve innervates sternothyroid?
ansa cervicalis
Origin and insertion of thryohyoid?
O - thyroid cartilage
I - body of hyoid
What nerve innervates thyrohyoid?
Ventral ramus of C1
The R common carotid originates from where?
Brachiocephalic trunk
The L common carotid originates from where?
aortic arch
The common carotids ascend to the level of?
superior border of thyroid cartilage
Where is the common carotid enclosed in?
Carotid sheath
The common carotid bifurcates into?
Internal and external carotids
T or F: There are branches of the internal carotid in the neck.
F
How does the internal carotid get into the cranium?
Via carotid canal of temporal bones
What is the main artery of the brain and orbits?
Internal carotids
The external carotids bifurcate into what?
Maxillary and superficial temporal arteries within parotid gland
How many branches of the external carotid are found in the neck?
6 (3 pairs)
What are the branches of the external carotid?
Ascending pharyngeal Occipital Posterior auricular Superior Thyroid Lingual Facial
What is the only medial branch from the external carotid artery?
Ascending pharyngeal
What are the posterior branches of the external carotid artery?
Occipital
Posterior auricular
What are the anterior branches of the external carotid?
Superior thyroid (first)
Lingual (second)
Facial (third)
The superior thyroid gives off what branch?
Superior laryngeal artery
The facial artery may share a common trunk with which artery?
Lingual
As the external jugular vein descends, what muscle does it cross?
SCM
Where does the external jugular vein form?
Near the angle of mandible
Where is the external jugular vein found deep to?
Platysma
The _______ pierces the investing fascia posterior to SCM
external jugular vein
External jugular vein empties into the _______?
Subclavian vein
Where is the anterior jugular vein formed?
Near hyoid
Where does the anterior jugular vein descend between?
SCM and the midline of the neck
Where does the anterior jugular vein empty into?
EJV or subclavian vein
T or F: There are variable communicaing veins between EJV and AJV
T
Where does the internal jugular vein begin?
Jugular foramen of the temporal bone
Where does the internal jugular vein descend in?
Carotid sheath
Order of neurovasculature in the carotid sheath?
Artery - medial
Vein - lateral
Nerve - posterior
T or F: The internal jugular vein passes superficial to SCM
F - it passes deep
How is the IJV accessible?
In the lesser supraclavicular fosa
The IJV and the subclavian vein merge to form what?
Brachiocephalic vein
Superior and middle thyroid veins are tributaries from what vein?
IJV
C2-C3 cervical plexus loop makes up what nerve?
Transverse cervical nerve
Transverse cervical nerve provides innervation to what?
Sensory innervation to the skin
Ansa cervicalis is made up of what?
C1-C2, C2-C3 cervical plexus loops
Ansa cervicalis provides innervation to what?
Motor to infrahyoid (except thyrohyoid) muscles
Hypoglossal nerve descends between what?
External carotid artery and internal jugular vein
The hypoglossal nerve is found deep to what?
posterior belly of digastric
The hypoglossal nerve provides innervation to what?
Motor to the muscles of the tongue
The vagus nerve is found where in the neck?
In the carotid sheath with carotids and IJV
Vagus nerve innervates what in the neck?
Pharyngeal and laryngeal (except cricothyroid) muscles
Deep neurovasculature passes through where?
The “root” of the neck, where the neck becomes thorax
Where is the root of the neck found?
Above superior thoracic aperture
The aortic arch is located where in relationship with the anterior scalene?
Superolaterally
The subclavian artery descends over ______ and posterior to ________.
1st rib
Clavicle
When does the subclavian artery become axillary?
When it crosses the lateral side of the 1st rib
There are how many parts of the subclavian artery?
3 parts
Boundares of the first part of the subclavian artery?
Medial to anterior scalene
What are the branches from the first part of the subclavian artery?
Vertebral
Internal thoracic (mammary)
Thyrocervical
At what level does the vertebral branch of the subclavian artery enter the transverse foramen?
C6
The internal thoracic (mammary) artery branch of the subclavian artery descends where?
Into the thorax
What are the branches of the thyrocervical trunk?
Inferior thyroid
Transverse cervical
Suprascapular
Which branch off the thyrocervical trunk is the major visceral artery?
Inferior thyroid
The transverse cervical artery supplies which muscles?
Trapezius
Levator scapulae
Rhomboid
What does the suprascapular artery supply?
supra/infraspinatus
What are the boundaries of the 2nd part of the subclavian artery?
posterior to anterior scalene
What branch comes off the second part of the subclavian artery?
Costocervical trunk
What does the costocervical trunk supply?
1st and 2nd intercostal spaces and posterior cervical muscles
What are the boundaries of the 3rd part of the subclavian artery?
Lateral to anterior scalene
What branch comes off the 3rd part of the subclavian artery?
Dorsal scapular
What does the dorsal scapular artery supply?
Medial scapular border muscles
The dorsal scapular artery passes between what?
trunks of the brachial plexus
Besides the 3rd part of the subclavian artery, where else could the dorsal scapular artery arise from?
Transverse cervical artery (deep branch)
Which branch of the common carotid is more anterior/posterior?
External carotid - anterior
Internal carotid - posterior
Usually, where does the common carotid bifurcate?
At the level of the hyoid bone, but not always
When does the axillary vein become subclavian vein?
lateral aspect of the 1st rib
Where does the subclavian vein course in relationship to the artery and the anterior scalene muscle?
The vein crosses anterior to the anterior scalene muscle, whereas the arter crossed posterior to the muscle
The merging of the subclavian and the internal jugular vein is called what?
Venous angle
the subclavian vein and the IJV unite to form?
Brachiocephalic vein
Major lymphatic trunks empty into what?
Venous angle, the merging of subclavian and IJV
The vagus nerve descends within what?
Carotid sheath
In the carotid sheath, the vagus nerve enters where in relation to the veins and arteries?
Enters the carotid sheath posterior to the veins and anterior to the arteries
The R recurrent laryngeal nerve recurs around what artery?
R subclavian artery
The L recurrent laryngeal nerve recurs around what?
The aortic arch
What do the recurrent laryngeal ascend in?
tracheoesophageal groove
The phrenic nerve is motor or sensory?
Motor
Where is the phrenic nerve formed?
Apex of scalene triangle (C3-C4 loop and C5)
The phrenic nerve is found where in relation to the anterior scalene?
Anterior to the anterior scalene
What arteries “strap down” the phrenic nerve?
Transverse cervical
Suprascapular
Where does the phrenic nerve enter the thorax?
Between the subclavian artery and vein
The phrenic nerve supplies what?
Motor supply to the hemidiaphragm and visceral afferents (pericardium, pleura, etc.)
Where is the sympathetic chain located in relation to the carotid sheath?
Posterior
The sympathetic chain is made up of how many ganglia and what are they called?
3 (most often)
Superior (largest)
Middle (sometimes absent)
Inferior (often fusted with 1st thoracic ganglion - stellate)
Where are the three main sympathetic ganglion found?
Superior - level of C1, C2
Middle - level of C6
Inferior - level of C7
Postganglionic sympathetic neurons can go what ways?
- Cervical spinal nerves (via gray rami communicantes)
- thoracic viscera (via cardiopulmonary splanchnic nerves)
- head/viscera of the neck (via cephalic/cervical arterial branches)
What makes up the brachial plexus roots?
Ventral rami C5-T1
What are the 4 supraclavicular branches of the brachial plexus?
Dorsal scapular
Long thoracic
Suprascapular
Subclavian
Where does the brachial plexus emerge through? What accompanies it?
The scalene triangle
Subclavian artery
What makes up the superior trunk of the brachial plexus?
C5 and C6 - suprascapular
What makes up the middle trunk of the brachial plexus?
C7
What makes up the inferior trunk of the brachial plexus?
C8 and T1
What are some reasons why you would use a central line?
Parenteral nutrition
Medications (like chemo)
CV monitoring (central venous pressure, or pulmonary artery)
What are the three veins where you can place a central line?
Subclavian
Internal jugular
Femoral
Where should the catheter tip lie when placing a central line in either the subclavian or IJ approach?
at the superior vena cava and R atrium junction
Where should you aim your needle for a subclavian approach for a central line?
The sternal notch, the midpoint of hte clavicle
What are the risks of a subclavian approach to a central line?
Pneumothorax and a subclavian artery puncture
What side is preferred for a IJ approach to a central line?
R
Where do you insert your needle and aim your needle for a IJ approach to a central line?
You insert in the apex of teh supraclavicular fossa and you aim toward the ipsilateral nipple
What are the risks of a IJ approach to a central line?
Pneumothorax and internal carotid artery puncture
In the carotid sheat, where is the vein in relation to the artery?
Vein is more posterior
What are some things to keep in mind when placing a central line?
Have the pt turn their head, arms by their sides
For an IJ approach, raise the head off the head of the bed
Where does plaque build up in the arteries most often?
Bifurcations
When is a patient symptomatic with carotid artery disease?
When it’s high grade or bilateral
Why is a pt asymptomatic with carotid artery disease for so long?
Because there is a lot of collarteral blood flow to the brain
What is a carotid endarterectomy?
Stripping of thickened intima and plaque, you repair the artery or with vein patch, a shunt can be used to preserve cerebral flow
Risks of carotid endarterectomy?
CN IV-VII injury
Ansa cervialis injury
Bradycardia/hypotension (carotid sinus)
High bifurcation (under the mandible)
