Surface Anatomy and Other Landmarks

1. Laryngeal prominence (Adam's apple) in the midline formed by the thyroid cartilage at approximately C4. 2. Inferiorly the ring of the cricoid cartilage may be palpated at C6. 3. The tips of the transverse processes of C1 are more prominent than those of other cervical vertebrae and can be palpated in the parotid space bilaterally between ramus of the mandible and mastoid process. 4. The hyoid bone: Its body is at the level of C3. It has lesser and greater horns bilaterally. 5. The thyroid cartilage lies at the levels of C4 and C5. The laryngeal prominence is Adam's apple in the male. The thyroid cartilage is composed of 2 lateral laminae with superior and inferior horns. The inferior horns articulate with the cricoid cartilage. 6. The cricoid cartilage is at C6. The upper end of the trachea is palpable in the midline from the cricoid cartilage to the superior border of the manubrium. 7. The thyrohyoid membrane is pierced by the internal laryngeal nerve and vessels. 8. The cricothyroid membrane may be used for a high tracheostomy. *The preferred site of tracheotomy is at tracheal cartilages 2-4 (below cricoid cartilage and isthmus of the thyroid gland).

Craniovertebral Joints

Atlanto-occipital joint: joint between atlas (vertebra C1) and occipital bone; movements flexion - extension of the neck (nodding the head in "yes" movement). Atlanto-axial joint: joint between atlas (C1) and axis (C2); movement: lateral rotation of atlas on axis (shaking head in "no" movement) Ligaments of joint - stabilize joints and protect medulla and spinal cord; some prevent excessive movement; some are extensions of ligaments of spinal column 1. Cruciate (cross) ligament - composed of

Transverse ligament of atlas: transverse band within vertebral canal which is attached to inner side of atlas; holds dens of axis against inner aspect of anterior arch of atlas Superior and inferior bands: upper and lower extensions from transverse ligament of atlas to occipital bone superiorly and to body of the axis inferiorly. Clinical note: Tear of cruciate ligament of atlas can allow dens to be driven into spinal cord (resulting in quadriplegia) or medulla (resulting in death).

2. Alar ligament: extends laterally from dens to occipital bone; prevents excessive rotation of head. 3. Tectorial Membrane : extension of posterior longitudinal ligament of spinal column - extends from axis to occipital bone, posterior to cruciate ligament. 4. Anterior atlanto-occipital membrane:= extension of anterior longitudinal ligament - extends from atlas to occipital bone

TRIANGLES OF THE NECK

A common method used to assist in the understanding and locating different structures in the neck is to geometrically separate the neck into triangular components and noting the contents and their relationships. The mastoid process located immediately posterior to the external ear (auricle) marks the superior attachment for the large sternocleidomastoid muscle as it passes to its attachment on the clavicle and sternum. This muscle separates the posterior triangle from the anterior triangle of the neck. It is best palpated by turning the head against pressure to one side and palpating the opposite side of the neck.

THE ANTERIOR TRIANGLE OF THE NECK

Using a simplified lateral view of the neck we can easily identify the Borders of the anterior triangle of the neck:

Midline of the neck from chin to manubrium Posterior border of the sternocleidomastoid Inferior border of the mandible

The Investing layer of deep cervical fascia anteriorly covers the anterior triangle of the neck and fuses with the opposite fascia in the midline. Contains the Suprahyoid and the Infrahyoid muscles:
Suprahyoid: Infrahyoid: Mylohyoid* Sternohyoid A Digastric-Ant* Sternothyroid A Digastric-Post** Omohyoid-Inf A (actually in the
posterior triangle but included here for the sake of comparison)

Stylohyoid** Omohyoid-Sup A

Geniohyoid*** Thyrohyoid***

Innervation: A = Ansa Cervicalis (c1, c2, c3) **=Facial Nerve * =Mylohyoid Nerve from the Inferior Alveolar Nerve of V3 *** = c1 Origins, Insertions and Actions can be reviewed in the text.

The anterior triangle of the neck can be further subdivided into:

Submental Triangle: between the anterior belly of the digastric, superior to the hyoid
bone, and the midline of the neck

Floor is formed by the mylohyoid muscle Most noted for the presence of several submental lymph nodes which drain the floor of the oral cavity, tip of the tongue and middle lower lip and central incisors Anterior jugular veins: Lying in the midline, running from the submental triangle, they pierce the deep fascia above manubrium. They pass between the posterior border of the sternocleidomastoid muscle and the upper border of the clavicle to drain into the external jugular veins in the posterior triangle of the neck.

Submandibular (Digastric) Triangle: between the posterior and anterior bellies

of the digastric muscle and inferior border of the mandible. Its floor is formed by the mylohyoid, hyoglossus and middle constrictor muscles.

Continuous with the fossa for the parotid gland Mylohyoid muscle lies superior to the anterior belly of the digastric o Forms a sling passing from side to side from its attachment to the internal surface of the mandible (mylohyoid line) o Forms the floor of mouth: It is attached from the mylohyoid line to the superior aspect of body of hyoid bone and the midline raph. o Around the free edge of this muscle lies the duct of submandibular salivary gland which occupies a significant part of the triangle o Associated with the anterior belly of digastric, as both are derived from the 1st Branchial Arch and therefore share the same innervation: Mylohyoid Br. of the Inferior Alveolar N. of V3 Hypoglossal nerve (CN XII) also passes into the triangle as it goes to the tongue between Hyoglossus and mylohyoid close to the hyoid bone Facial artery, arising from the external carotid, passes superiorly deep to the posterior belly of digastric, follows the floor of the triangle and winds posteriorly over the submandibular gland and "grooves" the inferior edge of the mandible at anterior-inferior angle of the masseter muscle to reach the face Posterior belly of the digastric: o Originates from the digastric fossa medial to the mastoid process, o Attaches to the anterior belly of digastric by the intermediate tendon which is tied down by a fascial sling to the body of the hyoid. o Associated with the stylohyoid, which arises from the lateral surface of the styloid process and it splits around the Common tendon of the digastric to insert into the hyoid bone. o Both muscles are derived from the 2nd Branchial Arch and therefore share the same innervation: Facial N. (CN VII)

THE POSTERIOR TRIANGLE OF THE NECK

Using a simplified lateral view of the neck we can once again easily identify the Borders of the posterior triangle of the neck:

Sternocleidomastoid anteriorly Trapezius posteriorly Clavicle inferiorly

Roof of the posterior triangle: Platysma and superficial layer of the deep cervical fascia (Only
platysma covers the vulnerable spinal accessory nerve crossing the posterior triangle)

Floor of the posterior triangle: A muscular floor and consists of the following muscles which are arranged, in order, from posterosuperior to anteroinferior: 1. Splenius capitis - ligamentum nuchae and upper thoracic spinous vertebrae to the mastoid process and occipital bone (draws head backward or to the respective side). 2. Levator scapulae - processes of C1-C4 to the superior aspect of the medial border of the scapula (elevates scapula). 3. Scalenus muscles a. scalenus anterior - anterior tubercles of the transverse cervical processes to the scalene tubercle of the 1st rib. b. scalenus medius - posterior tubercles of all of the transverse cervical processes to the first rib. c. scalenus posterior - posterior tubercles of the transverse cervical processes to the 2nd rib. All muscles of the posterior triangle, whether boundary or floor muscles, are enclosed by separate subdivisions of the deep investing fascia of the neck

Carotid Triangle: between the posterior belly of the digastric, superior belly of the omohyoid
and deep to the sternocleidomastoid muscle.
As the vascular area of the neck, it is most noted for the carotid sheath and its contents:

Common Carotid Artery Internal Jugular Vein Vagus N

The Common Carotid Artery arises in the base of the neck from the brachiocephalic artery on the right side and directly from the arch of the aorta on the left side in the superior mediastinum of the thorax. It passes into the base of the neck through the thoracic inlet bounded by T1 vertebral body, the sternum and first rib and ascends into the carotid triangle Medial to the artery is the esophagus and trachea Internal jugular vein lies lateral to it It can be compressed on the transverse process of C6 (the carotid tubercle). CN IX and the pharyngeal btranches of IX and X run between the internal and external carotid arteries Both CN Xl and XII run laterally to the internal and external carotid arteries Bifurcation into the internal and external carotid arteries occurs at the level of the upper border of the thyroid cartilage(C4) Internal: o Gives no branches in neck and simply ascends to enter the base of the skull into the carotid canal o Has the carotid sinus (baroreceptors associated with CN IX) at its beginning o The carotid body is present at the bifurcation and has chemoreceptors.

The carotid sinus and body are for mechanisms controlling blood pressure. o Lies posterolateral to the external carotid artery. o Cranial nerve IX or glossopharyngeal nerve runs anterior to the internal carotid artery and penetrates the lateral pharyngeal wall with the stylopharyngeus muscle. It is motor to this muscle and sensory to the mucosa of posterior 1/3 of tongue, mucosa of pharynx, palatine tonsil and soft palate. External: o o o Main arterial supply to structures of the neck and superficial face Gives off several branches, some of which originate in or pass through the carotid triangle. Lies inferior to (I), deep to (D) or superior to (S) the posterior belly of the digastric.

Branches of the External Carotid Artery can be described through SALFOP | SMAX
Superior thyroid artery (I) arises close to the carotid bifurcation. It descends anteriorly across the triangle to enter the superior pole of the thyroid gland anastomosing with its opposite counterpart and the inferior thyroid artery. Its branches are: The superior laryngeal artery supplying the inner aspect of the larynx The cricothyroid branch running with the external laryngeal nerve. The muscular branch to the sternocleidomastoid muscle.

Location Tip: Seen running with the internal laryngeal nerve piercing thyrohyoid membrane Ascending pharyngeal artery (I) arising near the carotid bifurcation from the posterior surface of the external carotid and passing posteriorly to the back of the pharynx. It supplies the pharyngeal constrictor muscles (lateral wall of the pharynx and the nasopharynx) and gives off small branches that supply the prevertebral muscles, middle ear and meninges, tonsil (palatine) Lingual artery (DI) passes superiorly deep to the suprahyoid muscles to enter and supply the tongue. It also gives branches to the suprahyoid muscles and the sublingual gland (tonsil) Facial artery (D) arises Immediately above the level of the hyoid bone and dips into the digastric triangle and around the submandibular gland. It ascends and crosses over mandible to supply the anteromedial aspect of the face (incl. lips, nose). It also sends branches to the palatine tonsil (tonsillar br.), the submandibular gland and on the face, to both the lips and the nose. It ends as the angular artery which anastamoses with the infraorbital Occipital artery (D) arises on posterior side of ext. carotid, opposite facial artery, above the ascending pharyngeal, sends branches to the SCM, the dura mater, and then courses to the back of the head to supply the scalp Location Tip: found by identifying the hypoglossal nerve (CN XII) which loops around it from posterior to anterior. Posterior Auricular (S) courses behind the external ear and helps to supply the scalp, the middle ear, and the auricle. Neuritis of CNVII might be due to compression of this artery due to proximity to the nerve. In general, palsy of CNVII is termed Bell's palsy. Superficial Temporal (S) Large terminal branch arising opposite external auditory meatus supplying the scalp on the lateral side of the head and giving off the transverse facial artery which courses across the face. Splits into parietal and temporal branches(Temporalis m.) Maxillary artery (S) second large terminal branch, is the principal artery of the deep face. It has 3 divisions and many branches in each division. It supplies the tympanic membrane, gives rise to the middle meningeal artery, supplies the muscles of mastication, all lower and some upper teeth, the infraorbital region, the hard and soft palate, and the walls of the nasal cavity. More information regarding the maxillary artery can be found in its dedicated section.

Branches of the External Carotid Artery can also be described using the following diagram:

Note how the structures are physically placed - which ones are posterior, anterior, etc- and use that as a guide not only for locating them on the cadaver, but also for memorizing the structures themselves. Internal Jugular Vein collects blood from the brain, face and neck Usually the largest vein in the neck As a direct continuation of the sigmoid sinus and the inferior petrosal sinus, it begins after exiting the jugular foramen. It is usually larger on the right, since the superior sagittal sinus drains to the right transverse and sigmoid sinuses in most people. Passes inferiorly through the carotid triangle receiving many tributaries from surrounding structures. At the base of the neck it unites with the subclavian vein on either side to form right and left brachiocephalic veins which in turn form the superior vena cava. Deep cervical lymph nodes lie along its course

Vagus nerve (CNX) The vagus has an extensive distribution as it conveys voluntary motor and sensory nerve fibers to structures in the neck, and viscero-motor fibers to thorax and abdomen. It enters the neck by exiting the skull through the jugular foramen. In the carotid triangle it lies behind and between the carotid and jugular vessels. Several branches are present. A pharyngeal branch passes between the internal and external carotid vessels to the middle constrictor of the pharynx to join branches from the glossopharygeal nerve to form the pharyngeal plexus. A superior laryngeal nerve arises below the pharyngeal branch and passes to the side of the larynx deep to both External and Internal Carotid Arteries. The superior laryngeal nerve from X divides into: The internal laryngeal branch which pierces the thyrohyoid membrane, is sensory to the piriform fossa of the pharynx and laryngeal mucosa above vocal cords and is involved in the coughing reflex. The external laryngeal branch which runs on the lateral aspect of the larynx to innervate the cricothyroid muscle (the only laryngeal muscle outside the larynx) which tenses vocal cords during vocalization.

Outside the triangle the important recurrent laryngeal branches arise. Other branches in the neck region include: (upper branches) voluntary motor nerves to the muscles of palate (except for the tensor veli palatini muscle which is innervated by V3), to the pharynx (except for the stylopharyngeus muscle which is innervated by CN IX) and to the larynx. (lower branches) parasympathetic preganglionic fibers to the cardiac, thoracic and abdominal regions sensory fibers to the inferior sensory ganglion lying in jugular fossa. sensory fibers to the skin of the external auditory canal with cell bodies lying in the superior sensory ganglion in the jugular fossa.

Ansa Cervicalis Lying superficial to the internal jugular vein and the carotid sheath, the ansa cervicalis forms a loop of nerve fibers whose principal function is to supply motor innervation to the strap muscles (except the thyrohyoid and geniohyoid). It is formed by 2 components: o Superior Loop (Descending Hypoglossi) anterior and lateral on the carotid sheath o Inferior Loop from cervical plexus: Loops from posterior to lateral of carotid sheath Leaves the hypoglossal as it turns anteriorly around the occipital artery C1 hitchhikers travel with the Hypoglossal Nerve: some of these fibers leave the Hypoglossal nerve in the neck and descend down (Superior Root) and join other nerves of anterior rami of C2 and C3 (inferior root) to innervate neck muscles (decendens hypoglossi) Other fibers of C1 travel further with the Hypoglossal nerve and jump off to innervate the Thyrohyoid and, later in the floor of the mouth, to Geniohyoid muscles Remember: Only hitch-hiking fibers from C1-C3 actually innervate neck muscles - not the Hypoglossal nerve itself Produce Sensory nerves: The great auricular nerve and transverse cervical nerves (anterior cutaneous nerve of neck) for C2 and C3 dermatomes.

Sympathetic Trunk Autonomic Nerve Fibers and Ganglia Lies posterior to the carotid sheath in the carotid triangle on the anterior aspect of longus coli (prevertebral muscle). May occur as a single band or as web-like filaments passing upward and therefore may be difficult to differentiate from fascia of the sheath. Preganglionic fibers arise from the superior thoracic spinal nerves T1-T4 to the sympathetic chain, which leave the thorax through the inlet and travel to cervical structures.They reach the trunk via white ramus communicantes. 3 Cervical Sympathetic Ganglia: Inferior: At the level of the 1st rib/C7 o o o Wrapped around the posterior aspect of the vertebral artery May be fused with the 1st thoracic ganglion to form the stellate ganglion Post-ganglionic fibers pass to C7, C8, heart, and vertebral plexus around the vertebral artery Middle: At the level of cricoid cartilage (C6)/Inferior thryoid artery o o Anterior to the vertebral artery Post-ganglionic fibers pass to C5 &C6, heart and the thyroid gland Superior: At the level of C1/C2, Largest Postganglionic fibers enter the cranial cavity via the internal carotid plexus and sends branches to the internal and external carotid artery, c1-c4, and the upper cardiac plexus