Gross Anatomy Forum Neck

Neck Forum

1) Identify the correlative vertebral associations exhibited by the following structures:

a) Hyoid bone
C3-C4
b) Thyroid cartilage
C4-C5
c) Cricoid cartilage (and esophagus begins)
C6
James Lamberg
2) Identify the fascial layers of the neck (7). What fascia layers are directly opposed in the
posterior triangle? What fascial components meet to encircle the visceral structures of the neck?
Layers: Superficial cervical fascia, Deep investing fascia, Infrahyoid (superficial and deep)
fascia, Deep cervical (pre-trachael and bucchopharyngeal) fascia, Prevertebral (alar, axillary
sheath, Sibson’s) fascia, and Carotid sheath.
(See Image #1)
Triangle: Investing layer of cervical fascia (Deep investing fascia)
Visceral: Deep investing fascia, Deep cervical fascia

3) Identify and describe the 4 major spaces delineated by the fascial layers of the neck.
Suprasternal, Pretracheal (visceral), Retropharyngeal, and Masticatory (See Image #2)
a) If an infection were to exist in each, to where would it dissect?
Suprasternal: Extends to jugulo-venous angle, bounded AP by the sternocleidomastoid fascia
Pretracheal: Extends from neck to superior mediastinum, bounded in front by infrahyoid muscles
and infrahyoid fascia, bounded in back by the trachea and pretracheal fascia.
Retropharyngeal: Retrovisceral space extends from base of skull to mid-cervical, bounded in
front by bucchopharyngeal fascia and in back by alar fascia. Danger space extends from the base
of the skull to the diaphragm bounded in front by pretracheal space.
Masticatory: Extends from jaw into neck and even danger space (e.g. abscessed tooth)

4) Draw the borders of the triangles of the neck.

Posterior Triangle: Trapezius (posterior), sternocleidomastoid (anterior), clavicle (inferior)
Posterior Sub-Triangles: Occipital triangle superior to supraclavicular triangle, split by the
omohyoid muscle
Anterior Triangle: Mandible (superior), sternocleidomastoid (posterior), midline of neck
(anterior)
Anterior Sub-Triangle – Muscular: Bounded by omohyoid, sternocleidomastoid, and midline of
the neck
Anterior Sub-Triangle – Submental: Unilateral triangle bounded by hyoid bone and anterior belly
of digastric muscle.
Anterior Sub-Triangle – Submandibular/Digastric: Bounded by anterior belly of digastric,
posterior belly of digastric, and mandible
Anterior Sub-Triangle – Carotid: Bounded by sternocleidomastoid, omohyoid, and digastric
(See Image #3 & #4)

5) Identify the veins that form the external jugular vein. Upon what structure does this vein
course? Where does it drain? What structure parallels its course?
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The posterior auricular vein and retromandibular vein (posterior division) fuse to make the
external jugular vein. The external jugular vein sits on top of the sternocleidomastoid, which
would make that a landmark for a venipuncture procedure. It drains into the subclavian vein. It is
paralleled by the great auricular nerve, which runs in the opposite direction.
(See Image #5)
6) Identify nerves and their cord levels of origin which innervate the skin of the following
regions:
a) Earlobe
Greater auricular nerve (C2-C3)
b) Superior aspect of shoulder
Supraclavicular nerve (C3-C4)
c) Midline of neck
Transverse cutaneous nerve of neck (C2-C3)
d) Lateral occipital region
Lesser occipital nerve (C2)
e) From what larger structure do these nerves originate? From behind what major landmark do
they appear in the posterior triangle?
The nerve point of the neck (originally from cervical plexus), behind the sternocleidomastoid.
(See Image #6)

7) Describe the pattern of lymph nodes in the neck.

Superficial lymph nodes make a ring around the head from the chin to the base of the skull. This
includes the submental, submandibular, external jugular, and anterior jugular lymph nodes.
Deep nodes run along the jugular veins starting at the jugulodigastric (“monster node”) to
superficial cervical, to deep cervical, to jugulo-omohyoid nodes, to jugular lymph trunks, and
finally into the jugular angle.

8) Describe the path of the spinal accessory nerve in the neck. Identify its innervations. What
nerves accompany it? How do you test its integrity?
The spinal accessory is closely associated with the internal jugular vein; both exiting out of the
jugular foramen of the skull. CN XI picks up proprioceptive fibers from the cervical plexus (C3-
C4). Near the top of the sternocleidomastoid, CN XI traverses perpendicular to that muscle
toward the trapezius, innervating both of these. One could test this muscle by having the patient
shrug their shoulders.

9) Identify the boundaries of the scalene triangle. What are its contents? What is the result of
their compromise?
The interscalene triangle is bounded by the clavicle, anterior scalene, and middle scalene. The
contents are the roots of the brachial plexus and the contributions to the phrenic nerve. Damage
to the plexus would result in loss of limb motor function and sensation. Damage to the phrenic
nerve would result in an inability to breath. More specifically, tightening of the scalene triangle
at the top/apex would show an upper brachial plexus problem (e.g. waiter’s tip) and movement
of the rib would give a lower brachial plexus problem (thoracic outlet syndrome, e.g. ulnar claw)

10) List the infrahyoid muscles, their general function and innervation.
Muscle Innervation Action
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Sternothyroid C1-C3 (ansa) Depress larynx

Sternohyoid C1-C3 (ansa) Depress hyoid
Thyrohyoid C1 (ansa) Depress and retracting hyoid, Elevates larynx
Omohyoid C1-C3 (ansa) Depress hyoid

11) Describe the location of the thyroid gland. The isthmus is described relative to which
structures? What is the pyramidal lobe? Describe the embryology of the thyroid gland. Why is it
important to be aware of the blood supply of this gland? Why can you not entirely remove this
gland?
An H-shaped endocrine gland below the laryngeal prominence. The isthmus crosses the trachea
at about the 2nd and 3rd cartilage rings. The pyramidal lobe is variable length and extends
superiorly from the isthmus.
Embryologically, the pyramidal lobe is remnant of the thyroglossal duct (midline mass would be
a thyroglossal cyst) and the lateral structures would form branchial cysts.
The inferior thyroid vein comes from the brachiocephalic trunk along the midline to the gland.
Thus, this would be damaged during attempts to access the trachea (e.g. emergency
cricothyroidotomy). Also, there is a variable artery, the thyroid ima, which runs along the
midline. This would also be at risk during certain procedures. Superiorly, removal of the thyroid
would require removal of the superior arteries, which are closely associated with nerves (e.g.
recurrent laryngeal).
The thyroid can be completely removed but the parathyroid glands cannot. Removal of those
glands, which manage calcium in the blood, would lead to constant muscular contraction. Tetany
of the diaphragm would prevent breathing.

12) What cranial nerves carry fibers from the cervical plexus?
CN XII carries C1 as it “hitches a ride” to the thyrohyoid and geniohyoid as well as the superior
root of ansa cervicalis (C1-C2). CNXI gets proprioceptive innervation from the cervical plexus
(C2-C4).

13) Identify the location of the esophagus relative to its origin and the trachea. Identify its
muscular construction. Identify its innervation. What escapes from behind it on its left lateral
side?
Pharynx ends and esophagus begins at C6. Esophagus goes down to diaphragm (T8).
Top 1/3 is skeletal muscle, bottom 1/3 is smooth muscle, middle 1/3 is mixed.
Innervation is the vagus nerve throughout. Historically, it was thought that the spinal accessory
nerve innervated the esophagus.
Thoracic duct is on the left lateral side.

14) Describe the carotid sheath:

The carotid sheath is lateral to the trachea/esophagus/thyroid.
a) What parallels its course and protects it?
Sternocleidomastoid, investing fascia
b) Where does it attach superiorly?
Base of the skull
c) Where does it end inferiorly?
Arch of the aorta (or brachiocephalic on the left side)

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d) Identify 5 nervous structures associated with it at the base of the skull

Spinal accessory nerve, hypoglossal nerve, vagus nerve, glossopharangeal nerve, and
sympathetic chain
e) Identify its contents
Common carotid artery, internal carotid artery, internal jugular vein, vagus nerve, superior root
of ansa cervicalis, and deep cervical lymph nodes.

15) Draw the sympathetic trunk in the neck. Identify the origins of fibers providing
preganglionic innervation. Identify the ganglia associated with the sympathetic trunk in the
neck. List the branches arising from the sympathetic chain in the neck.
Preganglionic sympathetic fibers for the viscera in the head arise from T1-T4.
Ganglia are superior cervical (C1-C4 ventral rami), middle cervical (C5-C6 ventral rami),
inferior cervical (C7-C8 ventral rami), stellate (C8-T1 ventral rami, cervicothoracic). The
branches follow the vasculature and include the internal carotid nerve, external carotid nerve,
gray rami, laryngopharyngeal branches, and cervical sympathetic cardiac nerves (highest cardiac
nerves). From the internal carotid nerve the branches are the caroticotympanic, deep petrosal,
and cavernouse plexus.
Horner syndrome signs (sympathetic lesion) would give ptosis (drooping eyelid), miosis
(pinpoint pupils), anhydrosis (dry face), and flushed face. If the internal carotid is out and the
external isn’t, you wouldn’t have anhydrosis or flushed face.
(See Image #7)

16) List the branches as they arise from the external carotid artery. Which branch:
(See Image #8)
a) At its origin is related to CN XII?
Occipital artery
b) Is visible in the superior reaches of the posterior triangle?
Occipital artery
c) Disappears deep to the hypoglossus?
Lingual artery
d) Arises near the bifurcation and courses directly to the base of the skull?
Ascending pharyngeal artery
e) May arise in common with another?
Lingual and facial artery
f) With another forms its terminal branches?
Superficial temporal and maxillary

17) List the branches of the vagus nerve in the neck and the arteries run with them.
Nerves run with vasculature. Superior laryngeal nerve (internal and external branches),
pharangeal branches, and recurrent laryngeal nerve. The superior thyroid artery runs parallel with
the external laryngeal nerve. The inferior thyroid artery runs parallel with the recurrent laryngeal
nerve.
(See Image #9)

18) List the parts of the subclavian artery and the associated branches.

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The subclavian artery is split into three parts in association with scalenus anterior; the second
part being behind the muscle.
First Part: Vertebral artery, thyrocervical trunk, internal thoracic artery
Second Part: Costocervical trunk, deep cervical artery
Third Part: Usually no branches, but sometimes superficial cervical arteries and/or suprascapular
arteries

19) Identify all structures crossing the superior thoracic aperture.

Trachea, esophagus, phrenic nerve, vagus nerve, recurrent laryngeal nerves, sympathetic trunks,
common carotid arteries, brachiocephalic trunk, subclavian arteries, internal jugular veins,
brachiocephalic veins, subclavian veins, lymph nodes, lymphatic vessels, muscles (e.g. longus
coli), and thoracic duct.
(See Image #10)

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Image #1 – Fascial Layers

Image #2 – Neck Spaces

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Image #3 – Neck Triangles

Image #4 – Neck Sub-triangles (Anterior Triangle)

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Image #5 – Neck Veins

Image #6 – Dermatomes
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Image #7 – Neck Sympathetics

Image #8 – Arteries
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Image #9 – Vagus Nerve

Image #10 – Thoracic Inlet

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