Neck- Wilson

Question 1

external occipital protuberance

Answer 1

found while dissecting the trapezius

Question 2

mastoid process

Answer 2

behind the ear

between is the transverse process of C2

Question 3

cricoid cartilage

Answer 3

is located at vertebral level C6

Question 4

hyloid bone

Answer 4

between C3 and C4 vertebrae

Question 5

sternocleidomastoid

Answer 5

has two heads

origin: sternum and the clavicle
insertion: attaches posteriorly behind ear to the mastoid process

-unilateral action of SCM will cause flexion of head ipsilaterally and rotation of the head contralaterally;
“kissing muscle” to put your head up after a date to kiss

-if you contract SCM muscle bilaterally you produce extension of the head posteriorly at the atlantooccipital joint (if this joint is fixed in position OR if you move your head all the way back and you continue to contract the SCM bilaterally . you will also cause flexion of the cervical vertebrae

SCM is crossing all the joints of the cervical vertebrae therefore flexing the cervical vertebrae but extending the atlantooccipital joint

Question 6

Clinically testing the sternocleidomastoid

What are the muscles that mask sternocleidomastoid ???

Answer 6

need to test against resistance as many muscles can mask or compensate for its paralysis

You’ll notice that one side is stronger than the other side

muscles that mask sternocleidomastoid:

• contralateral splenius capitis
• semisplenius capitis muscle (oblique head)

Question 7

sternocleidomastoid can be damaged at delivery

Answer 7

when pulling out the baby by pulling the shoulders, the obstetrician can tear or damage muscle; can end up tearing the SCM of the new baby because the baby has not been exercised much and their muscles may be very weak; those muscles are overtime damaged dead muscle fibers are replaced with scar tissue/collagen fibers which do not elongate

so if you damage a portion of the SCM at birth the length of that muscle will be the longest that it can be which is the length of the scar tissue

• this presents a problem that when the child continues to grow, the neck gets longer and longer and the SCM on the side that is damaged doesn’t elongate thus the head becomes progressively twisted towards the opposite side developing “wry” neck AKA Torticollis Congenital
• PT, massages, surgical repair

Question 8

What vessels are crossing the sternocleidomastoid?

Answer 8

external jugular vein: like the cephalic/saphenous vein, it is a superficial vein and is LARGE: important clinical because you can monitor it during physical exam (PE); as the artery start behind the ramus of the mandible it has to go superficial to deep to terminate and return blood back to the heart and it goes through the thick deep cervical fascia between the SCM and the trapezius and terminates in the subclavian vein; if this vein is cut by accident especially where it goes through the deep fascia (most veins when you cut they collapse due to low pressure) the fascia (tensed because it is between two strong muscles) will hold that vein open (lumen of the vein remains open); everytime the pt’s heart beats blood will be sucked into the right atrium and air from the external jugular vein can be sucked into the right atrium producing an air embolism either in the heart more likely in the pulmonary system–> respiratory distress and die

Question 9

external jugular vein

Answer 9

it is an excellent indicator of barometer; measures the venous pressure of a patient

external jugular vein will pop out; will have a lot of venous pressure when lifting weight or singing or during the Valsava maneuver

Question 10

Why is measuring the venous pressure of a patient important?

Answer 10

although the pt is sitting up and gravity should be pulling blood to heart because of elevated venous pressure the column of blood is not heavy enough to drain it so you distend and dilate the EJV and when you see that in a pt with other signs you’ll learn about you can make a pulmonary diagnosis of right heart failure or lung disease (due to heart attack or lung disease)

When the right side loses pumping power, blood backs up in the body’s veins.

Question 11

superior vena cava syndrome

Answer 11

SVC is being compressed by a tumor growing from the apex of the right lung this tumor is compressing the superior vena cava btw the ascending aorta which is of high pressure and the vein is of low pressure; put pressure on this SVC the vein will collapse; because you’re blocking the SVC, venous return from head and neck is obstructed which will cause a distension of the EJV, causing a pooling of blood in the EJV

Question 12

If a pt has lost blood, the initial procedure is to restore the volume of the vascular system by giving IV fluids. What should be monitored during this procedure?

Answer 12

To avoid administering IV fluids too rapidly, the EJV should be monitored for distension

• give IV fluid very quickly you can overwhelm the kidney and cause volume overload of her vascular system resulting in extension of the EJV; when administering check EJV to see if you are getting extension of the vein while giving IV fluid (if so you’re giving the IV fluids too quickly)

Question 13

Spock’s vulcan nerve pinch-What was his secret?

Answer 13

he’s grabbing the posterior border of the sternocleidomastoid; the other structures closely related to the posterior border of SCM are the sensory branches of the cervical plexus; Spock is injecting Chi (his own energy kung fu) to these nerve overwhelming the nerve with too much energy causing the person to collapse and fall to the floor

Question 14

What is the nerve point of the neck?

Answer 14

-found along the middle 1/3 of the posterior border of the sternomastoid

Sensory cervical (Cutaneous) NERVES:
-lesser occipital: runs parallel to the SCM
-greater auricular: runs obliquely across SCM toward the front of the ear
transverse cervical: goes across to the middle of the neck
-supraclavicular

a place where you can inject anesthesia which will affect the function of all those sensory cervical nerves innervating the skin of the neck
AKA cervical nerve block

Question 15

Motor component of the cervical plexus

Answer 15

-branches of C1 cervical nerve

CN XII: motor innervation to the tongue (hypoglossal); as it loops down next to the hyoid bone it gets a communicating branch from the first cervical nerve (VPR) and so some of the motor fibers in C1 travel with the hypoglossal and will be giving innervation to muscle such as the thyrohyoid; and some of the fibers will descend in the neck forming fibers called the descending hypoglossus carrying motor fibers to muscles below the hyoid bone (called infrahyoid muscles); coming the other direction are also branches coming from VPR of C2 and C3 and these are motor branches that are coming down and joining the descending hypoglossus which we call the descending cervicalis; when these two branches come together they form a ring called the ansa cervicalis; and it is from this loop the infrahyoid muscles get their innervation from

• descending hypoglossus= superior branch of the ansa cervicalis
• descending cervicalis= inferior branch of the ansa cervicalis

Phrenic nerve which is derived from C3-C5 to innervate the diaphragm

Question 16

Sternomastoid Divides the Neck into

Anterior and Posterior Triangles which are each consisted of?

Answer 16

posterior triangle:
SCM, trapezius, and clavicle

anterior triangle:
SCM, Mandible, Midline

Question 17

Posterior triangle is big and is subdivided into what two triangle by the posterior belly of the omohyoid muscle?

Answer 17

occipital triangle which is right below the occipital bone

subclavian triangle because of its content of the subclavian artery

Question 18

Occipital triangle

Answer 18

is crossed by the spinal root of CN XI which goes through the deep cervical fascia to innervate the trapezius

-this nerve is AKA the care-free nerve because it is so exposed and is not very well protected by structures underneath it and can be easily damage; because of its superficial course CN XI is vulnerable to injury, especially by surgeons vulnerable

• accessory lymph nodes are found along CN XI nerve
• these lymph nodes could become swollen and cause compression of the nerve

Question 19

subclavian triangle

Answer 19

smaller but much busier than occipital triangle

cut through fascia
remove the omohyoid

• 3rd part of the subclavian artery
• root of the brachial plexus (very important relationship)
• suprascapular artery: not important in terms of clinical
• supraclavicular lymph nodes: from left hand side getting lymphatic drainage from the upper abdomen and liver AKA sentinel/Virchow’s nodes (left quadrant of the abdomen) ONLY THE LEFT HAND SIDE

-they are name sentinel as they signal deep internal carcinoma including from the stomach, pancreas,, uterus, and esophagus

Question 20

supraclavicular lymph nodes swelling

Answer 20

enlargement of supraclavicular lymph nodes on the left side can be a warning to clinicians and pts that there is cancer below the diaphragm

-needs to be investigated because there may be a silent cancer that is destroying healthy tissue in the body that needs to be dealt with

Question 21

subclavian fossa with skin; remove the skin you see the subclavian triangle

Answer 21

important landmark clinically because

• subclavian artery crosses only the first rib (to become the axillary artery): if you have uncontrolled bleeding of the upper limb, this artery can be compressed to identify which artery has been severed
• brachial plexus crosses right through this subclavian fossa and therefore you can make a series of injection along the upper border of the clavicle (inject lidocaine) and produce anesthesia or paralysis of the upper limb
• brachial plexus nerve block (as just described)

Question 22

Where should your injection be made to anesthetize the brachial plexus?

Answer 22

above the middle of the clavicle into the subclavian fossa producing anesthesia and paralysis of the upper limb

Question 23

Scalene: between the brachial plexus (BP) and subclavian (SC) artery forms the floor of the anterior???? triangle

Answer 23

3 scalene muscles

• anterior and middle attach to the first rib
• posterior to the2nd rib

Question 24

The space between the anterior and middle scalenes is called the scalene triangle. What is significant about this triangle?

Answer 24

Neuromuscular bundle going through a small triangle of muscle.

• subclavian artery and roots of the brachial plexus pass through the scalene triangle
• a NM bundle going through a small triangle is a potential space for compression of the nerve by hypertrophy of the muscle, etc.

-subclavian vein DOES NOT go through this scalene triangle but goes anterior to it

Question 25

Thoracic Outlet syndrome

Answer 25

-thoracic outlet is defined by the space between the maneuver?? of the sternum and the 1st rib

-A cervical rib can grow into the scalene triangle, obstructing the artery and compressing the brachial plexus
disrupting motor fibers of the brachial plexus (inhibiting sufficient blood supply to the upper limb)

Question 26

Scalene anticus syndrome

Answer 26

tension of scalene muscles are too high

- like cervical rib syndrome but due to hypertonic scalene muscles producing sensory motor symptoms

Question 27

Anterior Scalene Divides the

Subclavian Artery into 3 parts. Describe the first part and its branches.

Answer 27

branches of the 1st part: (w.r.t. anterior scalene)

• vertebral (in front)
• thyrocervical trunk (behind)
• internal thoracic (lateral)

largest is the vertebral artery (one of the two major artery supplying blood to the BRAIN and spinal cord)

-initiation of anterior and posterior spinal arteries initiate in the vertebral artery

Question 28

vertebral basillar artery

Answer 28

-vertebral artery goes through the transverse foramen of C1 the artery takes an S-shaped turn to enter the foramen magnum and then the two arteries come together to form the basillar artery????

vertebral basilar artery supplies blood to the lower parts of the brain: brainstem which is inclusive of the medulla, pons, and midbrain

note the bend the vertebral artery has to make to reach the foramen magnum and the brain; this is important because bends can often allow for plaque formation because of turbulence which diminishes blood flow to the brain (turning of head can crimp that vertebral artery)

-turning the head can produce syncope if the vertebral artery is partially obstructed

Question 29

Scalene muscles can be accessory muscles in respiratory distress as they have attachment to the rib cage.

Answer 29

using the scalene muscles to elevate the rib cage to get more air into the lungs

fixation of arms which makes muscular origins from the rib cage the insertions

the pt has fixed his arm on the back of the chair is up because the insertion doesn’t move, what moves is the ribs going up

left heart failure

Question 30

phrenic nerve

Answer 30

-the nerve that innervates the diaphragm; carry GSE fibers to the diaphragm

• originates from C3, C4, and C5
• runs anteriorly on the anterior scalene

-if you remove the SCM you can see phrenic nerve running right on top of the SCM

Question 31

Anterior triangle is divided into what 4 triangles?

Answer 31

1) submental tri.
2) submandibular tri.
3) carotid tri.
4) muscular tri.

Question 32

submental triangle

Answer 32

contains submental lymph nodes draining the chin the very front part of the oral cavity (chin, central lower lip, tip of tongue, and anterior floor of the mouth) with origin of the external jugular vein

SHOULD NOT FEEL LYMPH NODES normally: cancer/infection of something going on in the oral cavity

Question 33

submandibular tri.

Answer 33

-has submandibular lymph nodes which are the main lymph node that drain the oral cavity
EXCEPTION is the submental

-submandibular gland (one of the 3 major salivary glands)

• facial artery
• lingual artery
• CN XII

Question 34

Submandibular gland can tell you about mumps/HIV. How so?

Answer 34

Gland can sometimes feel like a swollen lymph node. However the GLAND can get enlarged and swollen due to diseases like mumps and HIV.

-You can be able to distinguish which is the gland or the lymph node.

Part of the physical exam we’ll do is palpating the lymph node (the superficial cervical lymph node) that surround the base of the mandible and seeing if any lymph node are enlarged (due to tonsilitis, cancer of the oral cavity)

Question 35

carotid triangle

Answer 35

-contains the carotid artery which is the second major branch to the brain and the major branch supplying blood to the face

BOUNDARIES

• posterior belly of digastric
• superior belly of omohyoid
• anterior border of the sternocleidomastoid (SCM)

Small triangle but very important because of its content

Question 36

What are the contents of the carotid triangle as shown through the axial section through the neck?

Answer 36

carotid sheath: fascia/CT tube that surrounds the contents found in the carotid triangle:

• contains the carotid artery
• IJV: vein draining blood from brain
• vagus nerve: large cranial nerve in the body (is sandwiched between those two vessels located posteriorly)

Question 37

branches of the external carotid artery

Answer 37

????? see in anaomtuy lab

Question 38

carotid sinus

Answer 38

• carotid artery changes in the sheath and in the triangle
• common carotid body divides into internal carotid which has no branches up until the cranial vault and the external carotid that supplies all the branches to the neck, face, and head

between the two arteries where they bifurcate there are two sensory receptors:
-carotid sinus: neutral part of the internal carotid which is dilated (larger than nml) and has special sensory baroreceptors that are constantly monitoring how much blood pressure the brain is being perfused with; if you do not have enough pressure in the brain then the blood cannot travel all the way out to the distant capillaries (not enough pressure to push it all through that resistance) resulting in stroke as blood is not reaching those distal parts

(A baroreceptor)

Question 39

carotid body

Answer 39

has chemoreceptors that measure the PCO2 and PO2 of blood going to the brain

• it is important that the blood that goes to brain has sufficient oxygen so that neurons remain healthy
• this is involved in reflexes to ensure that at all time the blood going to the brain has sufficient oxygen

Question 40

carotid sinus and body important for?

Answer 40

-are involved in regulating HR and RR

Question 41

Carotid Endarterectomy

Answer 41

bifurcation is another area where plaques can form; this procedure is performed to remove the plaques

-his mother had this procedure done

Question 42

deep cervical lymph nodes

Answer 42

-draining everything in the head and neck except for the brain

BRAIN DOES NOT HAVE LYMPHATIC DRAINAGE

• found within the carotid triangle
• run with the internal jugular vein
• may be found in the carotid sheath or within its walls
• all structures of the head and neck drain into these nodes

-surgeons are challenged to remove cancerous nodes without damaging the vital structures within the carotid sheath

Question 43

swelling of the deep cervical lymph nodes

Answer 43

cancer in deep cervical lymph nodes affecting vagus nerve?????

Question 44

Horner’s Syndrome

Answer 44

when you have a lesion to the SNS (it can be CNS or PNS lesion); any lesion that disrupts sympathetic innervation of head and neck structures will result in Horner’s syndrome

symptoms include:

• palpebral pseudoptosis (partial drooping eyelid)
• miosis (constricted pupil)
• enophthalmos (sinking of eye into orbit)
• anhidrosis (dry skin)

Question 45

Muscular triangle and its boundaries

Answer 45

infrahyoid muscles which attach to the hyoid bone and are found inferior to the hyoid bone

BOUNDARIES:

• midline
• sternomastoid
• omohyoid, superior belly

Question 46

How do we get sympathetic innervation above T1-L2???

Answer 46

the sympathetic chain is located within or deep to the carotid sheath

sympathetic NS originates only from SC segments T1-L2 and if you follow the pathway that means for sure the dermatome T1-L2 will get sympathetic nerve fibers going to BV and sweat glands;

Exactly how do you get sympathetic fibers to the head and neck because that’s not where the sympathetic nervous system originates—through the sympathetic chain

Question 47

Where do preganglionic sympathetic fibers that innervate the head and neck originate?

Answer 47

preganglionic fibers originate in the Rexed lamina VII in the lateral horn (intermediolateral column) and those axons/fibers go out of the ventral root to the spinal nerve and leave the spinal nerve to enter the sympathetic chain; when they reach the sympathetic chain those fibers if they come at T1 or T2 some of those fibers don’t synapse in the sympathetic chain, instead they synapse at a higher level (like the cervical ganglia in the neck); once the synapse takes place, that’s what we call a post-ganglionic neurons its fibers a post-ganglionic fiber leaves and then are distributed with the dorsal and ventral primary rami of that particular nerve

Question 48

superior cervical ganglion in the internal carotid plexus

Answer 48

SNS in the neck also does something very interesting: some of these fibers go all the way up from T1 to the very last ganglion in the neck, synapse and some of those fibers go out of the DPR but some of these fibers continue with the sympathetic chain as it goes into the neck and form a plexus around the internal and external carotid arteries forming a network (hitchhike with that internal carotid artery) to go where those branches go and of course supply the smooth muscle (thus following the artery into the face and cranium)

internal carotid nerve–> internal carotid plexus which follows the artery with its branches to gain sympathetic control of the blood flow of that artery

Question 49

What are the muscles and contents of the muscular triangle?

Answer 49

infrahyoid muscles:

• sternohyoid
• omo(shouldeR) hyoid: goes from hyoid to scapula; has two bellies (superior and inferior)
• sternothyroid
• thyrohyoid

all innervated by the ansa cervicalis

-contents include larynx and the thyroid and parathyroid glands (both are endocrine glands)

Question 50

isthmus of the thyroid glands

Answer 50

isthmus is a connection between the right and left thyroid glands; it sits directly over the tracheal rings of 3 and 4; a relationship surgeons are interested in

Question 51

thyroid gland orginates with the tongue

Answer 51

embryology will be discusses with ziermann

if you look in the back of the tongue there is a depression called the foramen cecum which is where the thyroid gland originated in the neck (does not stay in the neck) and traveled to the lower lower larynx

Question 52

cyst in thyroglossal duct

Answer 52

sometimes the thyroglossal duct (with accessory thyroid glandular tissue) may persist connecting the thyroid gland and the foramen cecum of the tongue

-this is important because it is a duct that obliterates in the adult but that duct remains persistent; and if it is receiving secretions from these accessory gland it can develop a cyst

a cyst will present as a midline cyst running in the middle of the neck

-this is a cyst of the thyroglossal duct

Question 53

Differentials: How do you determine between the cervical cyst and a thyroglossal cyst?

Answer 53

think of embryology: What is the thyroglossal attached to?

• thyroglossal duct attaches to the tongue foramen cecum; cervical cysts do not have those attachment so what would you do to show that a bump in the midline is due to the thyroglossal duct?
• stick your tongue out and the cyst goes up, very simple

know your embryology, it makes perfect sense

Question 54

Goiter (enlarged thyroid gland)

Answer 54

enlarged and/or overactive thyroid gland may be removed by a “partial thyroidectomy” or radiation

• thyroid gland is responsible for regulating body metabolism and one of the clinical conditions that is associated with the thyroid gland is Goiter
• lump in the thyroid gland because it has gotten much larger
• having a Goiter may or may not indicate that the individual has an overactive thyroid gland; this means that in some instance pt may have an overactive thyroid gland but the thyroid is of normal size or the opposite is true, you have a huge goiter but the thyroid hormones in the blood is normal; so there is not a 1:1 relationship to the size of the thyroid gland and the concentration of thyroid hormones are in the blood

-Nevertheless it may be decided to remove this thyroid gland which can be done through radiation or a partial thyroidectomy

HYPOthyroidism: weight GAIN
HYPERthyroidism: weight LOSS

Question 55

If the thyroid gland fails to descend into the lower part of the neck, you have a lingual thyroid gland. Functionally, the thyroid gland can be anywhere in your stomach as long as it has a blood supply getting info from the pituitary it will function very well. But if you develop this why does it become complicated ????

Answer 55

if you develop a GOITER, there’s a complication as the goiter is going right back to the oral pharynx and of course this will make swallowing difficult producing dysphasia

Question 56

One of the hazards of doing a thyroidectomy is that there are other glands related to the thyroid gland which are called the parathyroid gland. Usually in most cases there are two parathyroid glands imbedded in each lobe of the thyroid gland on each side of the body. What is the action of the parathyroid gland?

Answer 56

these glands secrete parathyroid hormone that elevates blood calcium levels

• the actual location of the parathyroid glands varies ranging from thyroid cartilage to the superior mediastinum
• these parathyroid glands descend and are found in the thoracic cavity and the superior mediastinum, so the location of these parathyroid glands are not necessarily in the same place in every person but most times they will on the back of the thyroid
• when you do a thyroidectomy you DO NOT WANT TO REMOVE THESE glands as they control blood calcium levels (if you remove them, you MUST do parathyroid supplement because your blood calcium levels fall and the pt develops tetany (contraction of the muscles including heart and you die)

Question 57

What is the other hazard of having a thyroidectomy besides the parathyroid gland?

Answer 57

external and recurrent laryngeal nerve going to the larynx
-these can be severed by thyroidectomy resulting in dysfunction of the larynx itself

• speech could be affected (speaking with a whisper)
• these are very small nerves and it may not be the fault of the surgeon because as you remove the thyroid you may get swelling and edema of soft tissue which can compress these nerve resulting in malfunction of the larynx itself
• so it is advised before you do the surgery that you record the pt’s voice and know what the quality of their voice is in case they want to sue
• the external and recurrent laryngeal nerves are closely related to the thyroid gland; damage to either of these nerves by direct surgical trauma or postsurgical edema produces dysphonia

Question 58

Tracheostomy may be performed between the 2nd and 3rd tracheal rings. Why is the location important?

Answer 58

the thyroid gland is sitting over tracheal rings 3 and 4 and so this is a common surgical procedure

• tracheostomy: ostomy means window so you make a window in the middle of the trachea so that you can insert a breathing tube
• the problem with doing a tracheostomy is that you have to somehow reflect or cut through the thyroid gland or isthmus which has a lot of blood supply; so cutting through isthmus could produce a lot of bleeding and if you get a lot of bleeding the trachea the pt can aspirate their own blood and choke
• there are also blood vessels that are located here that can be opened up such as the inferior thyroid vein going up through the thyroid gland into the trachea; it is very large superficial vein and if you cut it you have bleeding into the trachea

Question 59

Thyroid ima artery

Answer 59

although rare, the thyroid ima artery can be a source of complication during a tracheotomy

this artery is variable and is not always present but nevertheless if it is present and you cut through that isthmus you get a lot of blood pooling into the trachea resulting in pt aspirating and choking on their own blood

Question 60

Pancoast syndrome (Thoracic Inlet tumor)

Answer 60

• a mass in the right superior thoracic aperture you find cancer invading structures you find in the root of the neck
• all these structures’ function could be affected (where you find CN X (vagus nerve), brachial plexus, and phrenic nerve: pressure on this nerve could stop breathing on one side of the diaphragm)
• typically results when a malignant neoplasm of the superior sulcus of the lung (lung cancer) leads to destructive lesions of the thoracic inlet and involvement of the brachial plexus and cervical sympathetic nerves (stellate ganglion).

Question 61

Any disruption to the sympathetic chain or nervous system of the head and neck can induce what symptoms?

Answer 61

• Horner’s syndrome
• pseudoptosis (one eyelid open, the other partially closed)
• dry skin
• pupils constricted

-As the brachial plexus goes through the root of the neck you have paresthesia and paresis of the upper limb

• superior vena cava syndrome
• dyspnea: damage to the diaphragm
• dysphonia: nerves to larynx are compressed and pt cannot speak normally
• dysphagia: nerves that innervate the esophagus are coming off the vagus nerve in the root of the neck so swallowing is impaired

-paralysis of 1/2 of the diaphragm

Question 62

The cupula and apex of lungs extends into the root of the neck. What may wounds produce?

Answer 62

pneumothorax

the apex of the lungs are surrounded by a pleura called cupula which extends into the root of the neck above the clavicle

-so a damage deep incision in that zone I on the neck to open up the pleural cavity can cause a pneumothorax because part of the pleural cavity extends into the neck allowing air or blood to go in resulting in collapsing of the lung

Question 63

Axial section right through Zone I: the 4 major fascia in the neck

Answer 63

• investing layer of deep cervical: surrounds both sides of the trapezius and those come together to surround the sternocleidomastoid which completely surrounds the neck; this is the fascia that the EJV goes through to reach the subclavian of the heart
• prevertebral fascia: found in front of the vertebral column and also surrounds the intrinsic(deep/dorsal) muscles of the neck
• pretracheal fascia: in front of the trachea and it completely surrounds the visceral tubes as well the glands
• carotid sheath: fascia that surround the carotid artery, internal jugular vein and vagus nerve

Question 64

What space is found in between the pretracheal and prevertebral fascia?

Answer 64

retropharyngeal space

-because it is a space behind the pharynx

pretracheal fascia goes around the entire visceral structures in the neck and extends to T4 where the trachea ends

Question 65

What space is found in between the pretracheal and prevertebral fasica?

Answer 65

retropharyngeal space extends from the base of the skull an into the thorax

• infections that enter the space can produce edema (an abscess) that obstructs swallowing (dysphagia) and/or breathing
• infection may also enter the thorax producing mediastinitis

Question 66

retropharyngeal space infection (absess)

Answer 66

mediastinitis
retropharyngeal abscess

-infection in the back of the pharynx (just like infection of psoas major following to
the femoral triangle) could go all the way down the space to where the pretrachial fascia ends at T4 where the trachea divides into the common bronchi

-pt could have a tooth removal or abscess in a tooth which reaches the retropharyngeal space and that infection goes all the way down to the mediastinum (this occurs very quickly); the abscess itself can become enlarged in the neck resulting in retropharyngeal abscess which can cause the mucosa of the larynx where the trachea is very very narrow can cause those mucous membranes to become swollen blocking breathing

Question 67

What are the zone of the neck used in the ER?

Answer 67

• Zone I is the root of the neck
• Cricoid cartilage (C6) separates Zone I and II
• angle of the mandible (jaw) separates Zone II and III
• Injuries of Zone I and III have the greatest risk of morbidity and mortality (because there are very large arteries and veins there and getting access to them are a challenge)
• Thankfully Zone II is most commonly injured in which you have access to control bleeding and further damage

Question 68

What are the major contents of Zone I that could be compromised if you injure this zone?

Answer 68

a. Viscera
- trachea
- esophagus
- cupula and apex of lungs

b. glands
- thyroid
- parathyroid

c. nerves
- vagus
- recurrent laryngeal
- phrenic
- sympathetic chain
- brachial plexus

d. blood vessels
-common carotid
subclavian artery and vein
-jugular veins

e. vertebral column

Question 69

Cervical plexus

Answer 69

is an arrangement of sensory and motor fibers formed from the ventral rami of spinal nerves C1 to C4

cutaneous branches innervate

• lesser occipital nerve: the skin of the occipital region
• great auricular nerve: outer ear and ear canal
• transverse cervical nerve: anterior aspect of the neck
• supraclavicular nerves: shoulder and upper thorax

muscular branches innervate

• ansa cervicalis: muscles attaching to the hyoid
• phrenic nerve: diaphragm and pericardium
• segmental branches: anterior and middle scalenes

Question 70

Preganglionic sympathetic fibers to the cervical ganglia:
originate from spinal cord levels T1-T5
enter the sympathetic chain
ascend to higher levels to synapse

Answer 70

After the synapse, the post-ganglionic fiber:
1. leaves the chain via a gray communicating rami
or
2. forms plexuses around and travel with arteries to each their targets.

Question 71

Arnold Chiari Malformation

Answer 71

Chiari I malformation describes low-lying cerebellar tonsils without other congenital brain malformations.

Chiari II malformation is a complex anomaly with skull, dura, brain, spine and spinal cord manifestations, which usually presents in early childhood or in infancy. This disorder is usually associated with the spinal defect myelomeningocele.
In type II Chiari malformation, both the cerebellum and the brain stem extend into the foramen magnum.

This condition may be associated with Hydrocephalus (typically due to aqueductal stenosis).