Triangles and Root of the Neck

BMES208 Human Musculoskeletal System

Kittikun Viwatpinyo, Ph.D.

Neck : Introduction
Neck (Cervical region)
Area in between base of skull to T1 vertebra, clavicle and acromion

Transitional area between head, thorax and upper limb

(Drake, Wayne & Mitchell, 2005)

Superficial structures of neck

Skin Superficial fascia Platysma muscle

(Tank, 2005)

Superficial structures of neck

Cutaneous nerves
Great auricular n. Lesser occipital n. Transverse cervical n. Supraclavicular n.

(Tank, 2005) (Moore, Dalley & Agur, 2010)

Superficial structures of neck

Superficial veins :
External jugular & Anterior jugular veins

(Moore, Dalley & Agur, 2010)

Deep cervical fascia

Investing layer Prevertebral layer Pretracheal layer Carotid sheath

(Moore, Dalley & Agur, 2010)

Fascial spaces
Potential spaces within neck Pretracheal space Retropharyngeal space Prevertebral space

(Moore, Dalley & Agur, 2010)

Fascial spaces
Potential spaces within neck Pretracheal space Retropharyngeal space Prevertebral space

(Drake, Wayne & Mitchell, 2005)

Anterior triangle of neck

Area anterior to sternocleidomastoid muscle Sub-triangles :
Submental Submandibular Carotid Muscular

(Moore, Dalley & Agur, 2010)

Skeletal landmarks
Hyoid bone Thyroid cartilage
Thyroid prominence Oblique line Thyrohyoid membrane

Cricoid cartilage

(Drake, Wayne & Mitchell, 2005)

Muscles of anterior triangle

Suprahyoid muscles
Digastric m. Stylohyoid m. Mylohyoid m.

(Moore, Dalley & Agur, 2010)

(Drake, Wayne & Mitchell, 2005)

Muscles of anterior triangle

Infrahyoid muscles
Sternohyoid m. Omohyoid m. Sternothyroid m. Thyrohyoid m.

(Moore, Dalley & Agur, 2010)

(Drake, Wayne & Mitchell, 2005)

Nerves of anterior triangle

Vagus nerve (CN. X)
Located within carotid sheath posterior to vessels

Major branch : Superior laryngeal n. Internal and External laryngeal nerves

(Drake, Wayne & Mitchell, 2005)

Nerves of anterior triangle

Hypoglossal nerve (CN. XII)
Located anterior to vessels and medial to digastric and stylohyoid muscles In submandibular triangle : located lateral to hyoglossus muscle

(Moore, Dalley & Agur, 2010)

Nerves of anterior triangle

Transverse cervical nerve (C2, C3)
Receives sensation from skin of anterior triangle

(Tank, 2005) (Drake, Wayne & Mitchell, 2005)

Nerves of anterior triangle

Ansa cervicalis
Loop of motor branches of cervical plexus (C1-C3) Located anterior to carotid sheath Superior and inferior roots Supplies infrahyoid muscles (except thyrohyoid m.)

(Tank, 2005)

Carotid arterial system

Common carotid artery
Bifurcates at level of upper border of thyroid cartilage

Internal carotid artery

Directs into skull No branches in neck

External carotid artery

Gives many branches to neck and facial structures
(Moore, Dalley & Agur, 2010)

External carotid artery : branches

Superior thyroid artery
Superior laryngeal a. : pierces thyrohyoid membrane to supply larynx Glandular branch : supply thyroid gland

(Drake, Wayne & Mitchell, 2005)

External carotid artery : branches

Lingual artery
Passes anteriorly and deep to hyoglossus muscle to supply tongue

(Drake, Wayne & Mitchell, 2005)

External carotid artery : branches

Facial artery
Passes anteriorly and medial to posterior belly of digastric muscle and travels along inf border of mandible Supplies submandibular salivary gland, submental region and face

(Drake, Wayne & Mitchell, 2005)

External carotid artery : branches

Occipital artery
Passes posteriorly and medial to posterior belly of digastric muscle Supplies sternocleidomastoid muscle and posterior part of scalp

(Drake, Wayne & Mitchell, 2005)

Carotid pulse

(Drake, Wayne & Mitchell, 2005)

Internal jugular vein

IJV : located lateral to common carotid a. Joins subclavian vein at venous angle Major tributaries
Facial vein Lingual vein Superior and middle thyroid veins Occipital vein
(Moore, Dalley & Agur, 2010)

Lymphatics of the neck

Superficial lymph nodes
Occipital nodes Mastoid nodes

Parotid nodes
Submental nodes Submandibular nodes Superficial cervical nodes

(Drake, Wayne & Mitchell, 2005)

Lymphatics of the neck

Deep cervical lymph nodes
Superior deep cervical nodes Inferior deep cervical nodes Pretracheal and Paratrachel nodes

(Moore, Dalley & Agur, 2010)

Posterior triangle of neck

Area posterior to sternocleidomastoid muscle Sub-triangles :
Occipital Omoclavicular

(Moore, Dalley & Agur, 2010)

Muscles of posterior triangle

Sternocleidomastoid muscle (SCM)
Origin : Mastoid process and lateral of sup nuchal line Insertion : medial 1/3 of clavicle and upper manubrium Nerve : Spinal accessory nerve (CN. XI)
(Drake, Wayne & Mitchell, 2005)

Muscles of posterior triangle

Sternocleidomastoid muscle : Actions
Extends neck (when in anatomical position) Flexes neck (when neck is initially flexes) Rotates neck to opposite side (unilateral)

(Moore, Dalley & Agur, 2010)

Muscles of posterior triangle

Scalene muscles
Scalenus anterior Scalenus medius Scalenus posterior

Main action : Flex neck and elevate ribs 1-2

(Drake, Wayne & Mitchell, 2005)

Nerves of posterior triangle

Accessory nerve (CN. XI)
Passes downward and posteriorly to supplies SCM and Trapezius muscles

(Tank, 2005)

Nerves of posterior triangle

Cervical plexus : from ventral rami of C1-C4
Muscular branches : Ansa cervicalis and Phrenic n. Cutaneous branches

(Moore, Dalley & Agur, 2010)

Nerves of posterior triangle

Cutaneous branches of cervical plexus
Lesser occipital n. (C2) : passes toward apex of post. triangle and supplies skin of posterior neck and scalp Great auricular n. (C2-C3) : parallels with EJV and supplies skin of parotid region and anterior ear
(Tank, 2005)

Nerves of posterior triangle

Cutaneous branches of cervical plexus
Transverse cervical n. (C2C3) Supraclavicular n. (C3-C4) : passes downward and laterally to supply skin of lower neck

(Tank, 2005)

Nerves of posterior triangle

Supraclavicular part of brachial plexus (root + trunk level)
Passes between scalenus anterior and medius muscles

(Drake, Wayne & Mitchell, 2005)

Nerves of posterior triangle

Terminal branches
Dorsal scapular n. (C5) Long thoracic n.(C5 C7) Suprascapular n. (C5, C6) Nerve to subclavius (C5, C6)

(Drake, Wayne & Mitchell, 2005)

Arteries of posterior triangle

Branches from Subclavian artery
Suprascapular artery Transverse cervical artery

(Drake, Wayne & Mitchell, 2005)

Root of the neck

Deep part of neck that connects with thorax (via superior thoracic aperture)
Floor : Apex of lung

(Drake, Wayne & Mitchell, 2005)

Root of the neck

Major contents : Subclavian vessels, Nerves, Lymph trunks, Visceral structures

(Moore, Dalley & Agur, 2010)

Subclavian artery
From Brachiocephalic trunk (right) and aortic arch (left)
Curves laterally in between Scalenus anterior and medius muscles Continues as Axillary artery Three parts (related with scalenus anterior muscle)

(Tank, 2005)

Subclavian artery : branches

First part : Vertebral a., Internal thoracic a. & Thyrocervical trunk Vertebral artery
Passes upward and medial to scalenus anterior m. Penetrates foramen transversarium (mostly C6) Supplies brainstem, cerebellum and posterior part of cerebrum
(Drake, Wayne & Mitchell, 2005)

Subclavian artery : branches

Internal thoracic artery
Pass downward to supply anterior thoracic wall

Thyrocervical trunk
Suprascapular a. Transverse cervical a. gives superficial and deep branches Inferior thyroid a.

(Moore, Dalley & Agur, 2010)

Subclavian artery : branches

Second part : Costocervical trunk
Give rises to Deep cervical artery and Superior thoracic artery

Subclavian artery : branches

Third part :
In 1/3 give rises to Dorsal scapular artery (replace deep branch of transverse cervical artery)

Subclavian vein
Subclavian vein
Continues from Axillary vein Passes anterior to scalenus anterior muscle and join IJV at venous angle Drained into Brachiocephalic vein

(Drake, Wayne & Mitchell, 2005)

Lymph trunks and nodes

At venous angle, lymph trunks join venous system:
Left side : Thoracic duct Right side : Rt lymphatic duct

Supraclavicular lymph nodes can be found along subclavian vein

(Moore, Dalley & Agur, 2010)

Nerves of root of the neck

Vagus nerve
Recurrent laryngeal nerve : passes in tracheo-esophageal groove to supply internal laryngeal muscles

(Drake, Wayne & Mitchell, 2005)

Nerves of root of the neck

Phrenic nerve (C3-C5)
Passes anterior to scalenus anterior muscle and descends into thorax to supplies diaphragm

(Drake, Wayne & Mitchell, 2005)

Nerves of root of the neck

Cervical part of sympathetic trunk
A bundle of sympathetic fibers posterior to carotid sheath Three ganglions (location of postganglionic sympathetic neurons)

Lesion : Horners syndrome

loss of sympathetic control in head

(Drake, Wayne & Mitchell, 2005)

Nerves of root of the neck

Cervical sympathetic ganglions
Superior cervical ganglion : sends symp fibers into head and neck along internal carotid artery Middle cervical ganglion sends symp fibers to heart Inferior cervical ganglion sends symp fibers to heart

(Drake, Wayne & Mitchell, 2005)

Thyroid and Parathyroid glands

(Drake, Wayne & Mitchell, 2005)

Trachea and Esophagus

(Drake, Wayne & Mitchell, 2005)