The Neck

787

A

Figure 8-4. Lateral aspect of the neck (right side), showing the cervical nangles that are used for descriptive purposes. A, The boundaries of ■e posterior triangle are: the clavicles, the posterior border of the ster-ocleidomastoid muscle, and the anterior border of the trapezius muscle. The boundaries of the anterior triangle are: the anterior border of the emocleidomastoid muscle, the inferior margin of the mandible, and

the anterior median line of the neck. B, Subdivisions of the cervical triangles. O indicates omohyoid; D, digastric; T, trapezius. Observe that the accessory nerve (CN XI) divides the posterior triangle into superior and inferior parts. Observe also that the inferior belly of the omohyoid muscle divides the posterior triangle into a large occipital triangle (su­ periorly) and a smaller supraclavicular triangle (inferiorly).

Occasionally the sternocleidomastoid muscle is injured at birth, resulting in a condition known as congenital torticollis or wryneck (Fig. 8-9). There is fixed rotation and tilting of the head owing to contracture of this muscle. Stiffness of the neck results from fibrosis and shortening of the muscle on one side. Because torticollis is a correctable condition, it is not usually seen in a more advanced form than that illustrated in Figure 8-9. Most cases of congenital torticollis result from fearing of fibers of the sternocleidomastoid when pulling the infant’s head excessively during a difficult birth, particularly in a breech presentation.

Triangles of the Neck
Each side of the neck is divided into two triangles, anterior and posterior, by the sternocleidomastoid muscle (Fig. 8-4). These cervical triangles, which are useful for descriptive pur­ poses, have a common boundary, the sternocleidomastoid.

The superficial fascia and the superficial layer of the deep fascia have been removed. Roof of the Po sterio r C ervical Triangle (Figs >-5 8). Superficial to the deep fascial roof are the fascia. The : :pital artery passes through the apex of the posterior triangle before it ascends over the posterior aspect of the head. 8* 8-7. The deep layer of cervical fascia forms a ‘T is: carpet” for the floor of the posterior triangle. . The clavicle forms the base of the in te rio r triangle. and 8-31). and scalenus posterior mus­ cles (Table 8-1).*r e ­ covers the space between the trapezius and sternocleidomastoid muscles. posteriorly by the ulterior border of the trapezius muscle. 7-3). . superficial veins. These muscles are covered by the prevertebral layer of deep cervical fascia. its apex is formed where the borders of the ^emocleidomastoid and trapezius muscles meet on the superior wtchal line of the occipital bone of the skull (see Fig. cutaneous nerves. This “ fascial carpet" is a lateral prolongation of the prevertebral fascia. Superficial dissection of the right side of the neck. i-4). C4 edial supraclavicular nerve Lateral supraclavicular nerve Intermediate supraclavicular nerve Figure 8-7 . platysma.cr. scalenus medius.The Neck 789 Auricularis posterior Occipital lymph node Great occipital nerve 0 - Occipital artery Sternocleidomastoid Great auricular nerve"] External jugular v e i n l Lesser occipital nerve “Fascial carpet” of posterior triangle Accessory nerve (CN XI) Cervical branch of facial nerve Transverse cervical nerve Platysma Nerve to trapezius from C3. The posterior triangle is covered by deep fascia. The fascial and muscular floor of mis triangle is formed (superior to inferior) by the splemiis cap:. pri­ marily to illustrate the posterior cervical triangle and its contents (Fig. arc Floor of the Po sterio r C ervical Triangle Fig> vv 8-10. the only motor nerve superficial to this “ carpet.” Posterior Triangle of the Neck B oundaries of the P osterior C ervical Triangle (Figs. Note the accessor* r. 8-28. and inferiorly by the rid d le third of the clavicle.:>. and 8-8). This triangle is bounded: anteriorly by the x-sterior border of the sternocleidomastoid. levator scapulae.

However. Deeper dissection of the right side of the neck than that shown in Figure 8-7. It crosses the sternocleidomastoid muscle in the superficial fascia and then pierces the deep fascial roof of the posterior cervical triangle at the posterior border of this muscle. just inferior to the lobule of the auricle. The external jugular vein passes obliquely through the inferior part of posterior triangle and usually ends by emptying into the sub. The external jugular vein begins near the angle of the mandible. The subclavian vein is the major venous channel draining upper limb. 8-7. Observe the nerves that are deep to the “ fascial carpet” covering the muscular floor of the posterior triangle.790 Clinically Oriented Anatomy Semispinalis capitis l is Occipital artery j ry Splenius capiti Sternocleidomastoid t Great auricular ner* External jugular ve ? Nerves to levator scapulae Transverse cervical nerve Supraclavicular nerves Accessory nerve Internal jugular vein Nerve to rhomboids Scalenus medius Nerve to serratus anterior Transverse cervical artery Phrenic nerve deep to “fascial carpet” I Brachial plexus |_Scalenus anterior Omohyoid Pectoralis major Figure 8-8. It lies posterior to the clavicle and so is not re in the posterior triangle. about 5 cm superior to the clavicle. and 8-12). The external jugi vein drains most of the scalp and face on the same side. the external jugular vein is either invisible or observable for onh a short distance superior to the clavicle. by the union of the posterior division of the retromandibular vein with the posterior auricular vein. but it may rise as far superiorly as subclavian artery. when ven- . 8-12). V eins in the Posterior C ervical Triangle (Figs. 8-8. Contents of the Posterior Triangle The posterior cervical triangle contains mostly vessels and nerves that connect the neck and upper limb (Fig. When venous pressure is within the normal range. vian vein about 2 cjn superior to the clavicle.

8-8. Table 8-1). Its attachments.Omohyoid fascia Suprascapular * Axillary arte". The splenius (G. This thick straplike muscle is composed of four k bound slips. levator scapulae. This is the larger superior part of the splenius mus­ cle. see aL 6-40). 8-11. This is the longest and largest of the scalene mu>c attachments. 8-10A and 8-11. 810 to 8-12. nerve supply. 8-10 to 8-12. splenion. and 8-16 to 8-18. C6 . and main act: given in Table 8-1. note that the scalenus medius lies p o su the ventral rami (roots) o f the brachial plexus and the tin . and main actions are given 8-1. 789). Note that the phrenic nerve is related to the anterior surface of the scalenus anterior muscle paralyzed by a cervical nerve block. The needle is directed inferomedially toward the first rib (see Fig. nerve supply. and main actions are in Table 8-1. 34). and scalenus posterior. a bandage) sen “ bandage” that covers and holds the deeper muscles of th in place. pular nerve and the superior two roots of the long thoracic In Figure 8-11. As its name levator iL indicates. 4-41). 8-105 and 8-11. 1-5). the anesthetic agent is injected around the supraclavicular part of the brachial plexus of nerves. The subclavian artery is located by palpation before making the injection to avoid entering it. this muscle elevates the scapula. The main site of injection is superior to the midpoint of the clavicle. The Scalenus Medius Muscle (Figs. nerve supply. 8-8. ¿ Figure 8-11. As described (p. this procedure is not performed on patients with pulmonary or cardiac disease. M uscles in the P osterior C ervical Triangle (Figs.794 Clinically Oriented Anatomy Splenius capitis Levator scapulae Nerves to levator scapulae Accessory nerve — Supraclaviculc' Scalenus medius I ius Nerve to rhomboidss j id Phrenic nerve Scalenus ante . Its attachments.: Accessory phrenic Transverse cervical arten Scalenus posterior Serratus anterior and nerves C5. and 8-12). Dissection of the right side of the neck and superolateral part of the thorax. The deep fascia (“ carpet” ) covering the floor and part of the clavicle have been removed. four muscles form the floor of the posterior triangle. showing the muscles forming the floor of the posterior cervical triangle. From superior to inferior they are: splenius capitis. The Levator Scapulae (Figs. see also Fig. It is partially covered by the stemo mastoid and trapezius muscles. The middle scalene muscle is perforated by the don. The Splenius Capitis Muscle (Figs. For anesthesia of the upper limb. scalenus medius. Brachial Plexus Block (Figs.

The slender inferior belly of the straplike omohyoid muscle G. Efferent lymph vessels pass to the supraclavicular lymph nodes in the supraclavicular (subclavian) triangle of the neck (Fig. Its attachments. noting the the omohyoid muscle and its fascia have been removed to show the third part of the subclavian artery and the subclavian vein. also passes through the inferior part of the posterior triangle (Figs. Lym ph N odes in the Posterior C ervical Triangle (see Fig. 8-45) and a small inferior supraclavicular triangle. Observe the brachial plexus of nerves passing to the upper limb and the parts of the subclavian vessels that ire in the posterior cervical triangle. 8-45) was given its name because the occipital artery appears in its apex (Fig. This is the smallest and most deeply situated of ihe scalene muscles. Subdivisions of the Posterior Cervical Triangle The inferior belly of the omohyoid muscle divides the pos­ terior cervical triangle into a large superior occipital triangle (Fig. 8-1).4 5 ) . but it is very close to it. which is described with the infrahyoid muscles (Fig. shoulder). There is a superficial group of cervical lymph nodes along the external jugular vein and a deep group accompanying the internal jugular vein. The external jugular vein and suprascapular . nerve supply. The occipital triangle (Fig. The most important nerve crossing the occipital triangle is the accessory nerve (CN X I) . 8-8). The supraclavicular (subclavian) triangle is the smaller sub­ division of the posterior cervical triangle (Fig. Its location is indicated on the surface of the neck by the supraclavicular fossa (Fig. 8-16. These nodes receive afferent lymph vessels from the parotid. Compare with Figure 8-11. 8 . artery. Note that the internal jugular vein (usually the largest vein in the neck) is not in the posterior triangle. Table 8-3). 512-525). ~-32). This muscle is not completely separated from the scalenus medius muscle.The Neck 795 Trapezius Sternocleidomastoid Levator scapulae Branches of C5 [ Phrenic nerve Accessory phrenic nerve Scalenus pos teriori "sverse cervical artery Branch of C6 Scalenus anterior Internal jugular vein Serratus anterior Brachiocephalic vein Suprascapular nerve. 8-11 and 8-12). and mastoid lymph nodes and from vessels in the muscles and skin. 8-45). occipital. Close up of a dissection of the right side of the neck and superolateral part of the thorax. The Scalenus Posterior Muscle (Figs. om os. The omohyoid muscle is an important landmark in the neck. A detailed discussion of the brachial plexus appears in Chapter 6 (pp. and main actions are given in Table 8-1. it can often be seen contracting when some people speak. 8-45 and 8-11). and vein Subclavian vein Deltoid Axillary artery and vein Figure 8-12. of the subclavian artery. especially those with thin necks.

8-17). 8-19 and 8-24). 8-18). a branch of the inferior alveolar nerve (Figs. The submandibular gland nearly fills this tri­ angle. At the level of the superior border of the thyroid cartilage. Because of the location of these glands (Fig. it becomes painful to open the mouth and to eat. This deep process separates the superficial and deep parts of the subman­ dibular gland. It is easily felt when the mylohyoid muscle is tensed by forcing the tip of the tongue against the maxillary incisor teeth. hyoglossus. It wraps itself around the free posterior border of the mylohyoid muscle. which is motor to the intrinsic and extrinsic muscles of the tongue. Its pulse can be auscultated (L. this salivary gland is usually palpable as a soft mass between the body of the mandible and the mylohyoid muscle. the ‘ ‘digastric triangle. which is produced at the side of the lingual frenulum by the sublingual gland (see Figs. or it can be palpated by placing the digits in the triangle and compressing the artery lightly against the transverse processes of the cervical vertebrae. (Figs. the common carotid artery divides within the carotid triangle (Fig. It sends a thin sheet of muscle superior to this muscle. to listen to) with a stethoscope. and the cervical branch of the facial nerve in the subdivision of the anterior triangle called the submandibular triangle (Fig. passes from the deep process of the gland. from anterior to posterior.g. The swelling formed by the enlarged gland can be seen easily and palpated. This is a slight . lymph nodes (green). Contents of the Submandibular Triangle (Figs. 8-16). and parts of the facial artery and vein also pass through the submandibular triangle (Fig. not unlike the capital letter U on its side. The nerve to the mylohyoid m uscle. The submandibular gland. about 5 cm in length (Fig. The Carotid Sinus (Figs. About half the size of the parotid. anterior belly Facial vein Facial artery Facial nerve. ’ ’ The flo o r o f the submandibular triangle is formed. 8-24) into the internal and external carotid arteries. by the following muscles: mylohyoid. cervical branch Submandibular gland Retromandibular vein Facial vein Internal jugular vein | Superior root of ansa cervic alisj Inferior root of ansa cervicalis o Thyrohyoid Superior thyroid vein Sternocleidomastoid branch of superior thyroid artery Figure 8-16. This vascular area is bounded by the superior belly of the omohyoid. The carotid triangle is an important area because the common carotid artery and its branches ascend into it (Fig. The C arotid T riangle (Figs. In Figure 8-16. 8-14 and 8-17). passes into the submandibular triangle. 8-4 and 8-16 to 8-22). and the anterior border of the sternocleidomastoid muscle. They lie on the submandibular gland and along the inferior border of the man­ dible. the posterior belly of the digastric. Superficial dissection of the anterior triangle of the neck. may become inflamed (e. Observe the submandibular gland. 8-42?). 7-85 and 7-102). The sub­ mandibular duct opens on an elevation. The submental artery is a branch of the facial artery (Fig. owing to mumps). 8-16).The Neck 799 Great auricular nerve Accessory nerve ™ Sternocleidomastoid branch of occipital artery____ Digastric. The submandibular duct. and 8-17). 8-14). 7-25 and 8-17). 8-14. The hypoglossal nerve (CN XII). 816. to open by one to three orifices into the oral cavity. parallel to the tongue. the sublingual papilla. note the position of the submandibular lymph nodes. along with the parotid gland.. and middle constrictor of the pharynx.

8-17). ^Sternothyroid |_Sternohyoid Omohyoid fascia Anterior jugular vein Sternocleidomastoid Figure 8-17. Pressure on the carotid sinus may cause syncope (fainting). important for approaches to: (1) the internal jugular vein. 8-33).. (2) the vagus (CN X) and hypoglossal (CN XII) nerves.. Observe that the facial and lingual arteries in this dilation of the proximal part of the internal carotid artery. owing to the parasympathetic out­ flow from the brain through the vagus nerve (Fig. it is recommended that you not practice this on your . 7-74). The carotid sinus reacts to changes in arterial blood pressure and effects appropriate modifications reflexly.a I Internal laryngeal nerve [infe rior constrictor . The carotid triangle provides an important surgical ap­ proach to the carotid arterial system (Fig. Although the common carotid artery can be oc­ cluded by compressing it against the carotid tubercle of the C6 vertebra (Fig. e.Thyrohyoid t # External laryngeal nerve Superior thyroid artery Transverse cervical vein — --------. for control of hemorrhage in the neck. and 8-28). The sinus is also supplied by the vagus nerve and the sympathetic division of the autonomic nervous system (Figs. and if the person happens to have a supersensitive carotid sinus.g. it may cause cessation of the heart beat (temporary or permanent). The carotid sinus responds to an increase in arterial pres­ sure by slowing the heart.. 8-22 and 8-28). It is also person arise by a common trunk that passes deep to the stylohyoid digastric muscles to enter the submandibular triangle. it may involve the common carotid. 8-22. 8-21. 8-29). Deeper dissection of the right side of the neck than that shown in Figure 8-16. A blood pressure regulating area. and (3) the cervical sympathetic trunk (Figs..800 Clinically Oriented Anatomy Common trunk of facial and lingual arteries Fascia enveloping submandibular gland Stylohyoid External carotid artery Occipital artery — Hypoglossal nerve | Accessory n e r v e l Superior root of ansa cervicalis” I Sternocleidomastoid artery Internal carotid artery | External carotid a r t e r y l Ansa cervicalis I Common carotid a r t e r y l Internal jugular vein | _ _ Sternocleidomastoid b ran ch ! Sternocleidomastoid “Fascial carpet” of posterior triangle _ C [bnl Smt uea _ Hyoid bone Mylohyoid Facial artery arte'"* Nerve to mylo h.— — Jm m I f ^ .. the carotid sinus is innervated principally by the glossopharyn­ geal nerve (CN IX) through a branch called the carotid sinus nerve (see Fig.

7-2). the submandibular and deep cervical lymph nodes would also be involved because they receive lymph from the submental nodes (see Fig. 8-17. the relations of the thyroid gland and carotid sheath. Observe the carotid sheath and its contents (see also Fig. Transverse section of the neck showing. 8-17. a subdivision of the anterior cervical triangle (see also Fig.Pretracheal fascia ------------------------------------Left recurrent laryngeal nerve Figure 8-21. The submental triangle also contains small veins that unite to form the anterior jugular vein (Fig. Structures in the carotid triangle. 8-32. 8-4#) is used surgically for approaches to the thyroid and parathyroid glands and for exposure of the trachea. 8-21). and 8-23). The S u hm ental T riangle (Figs. posterior belly. 7-32).Vertebral body Thyr0id 9'and carotid artery-----------------------Anchoring b a nd--------------------------------------' Trachea ------------------------. This unpaired suprahyoid area is bounded inferiorly by the body of the hyoid bone and laterally by the right and left anterior bellies of the digastric muscles. External carotid artery Facial artery Hyoglossus Mylohyoid CN XI Lingual artery CN XII Internal jugular vein Carotid sheath Common carotid artery CN X Figure 8-22. the thyroid and parathy­ roid glands). 8-20. 8-16 and 8-31. The apex o f the submental triangle is at the symphysis menti (see Fig. 8-16. In advanced cancers of the central part of the lip. which meet in a median fibrous raphe. 7-32). Depending on the site of the lesion. and inferior levels of the carotid-jugular vascular system (Figs.. the mandibular incisor teeth and associated gingivae. and its base is formed by the hyoid bone. and 8-36). The flo o r o f the sub­ mental triangle is formed by the two mylohyoid muscles. and the skin of the chin. Observe that all the vessels and nerves cross deep to the posterior belly of the muscle (see also Figs. The muscular triangle (Fig. see also Figs. (Table 8-3) and the neck viscera (e. 8-17 and 8-18). 8-45). the floor of the mouth. Internal carotid artery Digastric.— ^ — — --------------. 6-33 and 7-29). metastases spread to the submental nodes from the central part of the lower lip and to the submandibular nodes from other parts of the lip.g. Most cancers of the lip occur on the lower lip and tend to spread through the lymphatic system. . esophagus. 8-25. the central part of the lower lip. The submental triangle contains the submental lymph nodes. which receive lymph from the tip of the tongue. Note that the intermediate tendon of the digastric muscle is attached to the hyoid bone by a fascial sling. running from the mastoid process of the temporal bone to the hyoid bone. see also Fig. Lymph from the submental lymph nodes drains into the submandibular and deep cervical lymph nodes (Figs. 8-4B. Note the key position of the posterior belly of the digastric muscle. in particular.The Neck 803 Esophagus---------------—----------.

8-4Z?). A plexus of sympathetic fibers accom­ panies it. bounded inferiorly by the body of the hyoid bone and laterally by the right and left anterior bellies of the digastric Most arteries in the anterior cervical triangle arise from the common carotid artery or one of its branches. it has no branches in the neck. to enter the carotid canal in the petrous part of the temporal bone (see Figs. the orbit. the internal carotid artery and its branches supply the hypophysis cerebri (pituitan gland). muscles (see als6 Fig. 7-42). Superficial dissection of the anterior aspect of the neck. 7-65 and 7-42). 8-17 to 8-22 and 824). W ithin the cranial cavity. almost in a vertical plane. posterior to the left sternoclavicular joint. The internal carotid artery enters the middle cranial fo ssa beside the dorsum sellae of the sphenoid bone (see Fig. and 8-29). The right common carotid artery begins at the bifurcation of the brachiocephalic trunk. As its name indicates. Observe that it contains some submenu! lymph nodes and that the floor of the submental triangle is formed b> the two mylohyoid muscles.804 Clinically Oriented Anatomy Submental lymph node Submental branch of facial artery —— -“Digastric. This is the direct continuation of the common carotid artery. 8-28. The C om m on C arotid A rteries (Figs. 8-24. 7-54). During its course through the neck. and most of the supratentorial part of the brain (see Fig. 8-25. The Internal Carotid Artery (Figs. posterior to the right sternoclavicular joint. Note the submental triangle. 8-22). 8-17 to 8-22. the internal carotid artery lies on the longus capitis muscle and the sym­ pathetic trunk. . Each common carotid artery ascends within the carotid sheath to the level of the superior border of the thyroid cartilage. The internal carotid ar­ teries are two o f the fo u r major arteries that supply blood to the brain (see Fig. the internal or external carotid arteries. The vagus nerve (CN X) lies posterolateral to it (Fig. 7-54). where it terminates by dividing into the internal and external carotid arteries. Each artery arises from the common carotid artery at the level of the superior border of the thyroid cartilage and passes superiorly. it supplies structurej within the skull. anterior belly Mylohyoid Fascia covering submandibular gland Omohyoid Laryngeal prominence Sternohyoid Cut edge of investing layer of deep cervical fascia Vein connecting facial and anterior jugular veins Pretracheal fascia Sternal head Clavicular h e a d j Sternocleidomastoid Sternothyroid Jugular venous arch Suprasternal space Figure 8-23. The left common carotid artery arises from the arch of the aorta and ascends into the neck.

8-12. see also Fig. 8-8. the auricle. 1-41A and C). the parotid gland. Posterior auricular a. Most of the veins in the anterior cervical triangle are tri­ butaries of the large internal jugular vein. Usually the largest vein in the neck. Table 8-4. Facial a. Occipital a. 8-16. and the scalp. This large vein commences at the jugular foramen in the posterior cranial fossa. 8-18 and 8-24.806 Clinically Oriented Anatomy Internal laryngeal nerve Thyrohyoid membrane Superior laryngeal artery Inferior constrictor External laryngeal nerve Sternothyroid. structures in the temporal bone. the facial nerve. Ascending pharyngeal a. Dissection of the anterior aspect of the neck. 7-43). Branches of the External Carotid Artery Surface Branches Figure R eferences Anterior1 Posterior Medial Superior thyroid a. between the trapezius and sternocleidomastoid muscles. The posterior auricular artery (Figs. 821. and 8-22. Lingual a. 8-17. the internal jugular drains blood from the brain and superficial parts of the face and neck. arises from it at the superior border of the posterior belly of the digastric muscle. It ascends posterior to the external acoustic meatus and supplies adjacent muscles. Its course corresponds to a line drawn from a point immediately inferior to the external acoustic meatus to the medial end of the clavicle. The isthmus of the thyroid gland is divided and its left lobe is retracted. reflected Superior thyroid vessels Right and left cricothyroids Fascial band [Trachea I Recurrent laryngeal nerve Common carotid artery Vagus nerve Internal jugular vein Common carotid artery Vagus nerve Internal jugular vein Thoracic duct Subclavian artery Sternothyroid Clavicle Jugular notch Figure 8-25. 7-35) is a small posterior branch of the external carotid. it passes superficial to the internal carotid artery and three cranial nerves (CN IX. It The Internal Ju g u lar Vein (Figs. as the direct continuation of the sigmoid sinus (see Fig. see also Fig. and CN XI). CN X. 8-18 8-22 8-17 8-17 8-18 8-18 and and and and and and 8-25 8-24 8-18 8-24 8-24 8-24 'The three anterior branches o f the external carotid artery are o f major im portance. During this course. From the dilation at its origin. called the superior bulb .

106). 8-29). the ventral rami from C3. The unexpected innervation of the diaphragm by cervical nerve roots has an embryological basis and clinical signifi­ cance (Moore. The phrenic nerve crosses posterior to the subclavian vein on both sides and anterior to the internal thoracic artery to enter the thorax. 1-62. loops around the subclavian artery on the right side and around the arch of the aorta on the left side. 8-12. a branch of CN X. 8-28. and p. Injuries to the inferior cervical region of the spinal cord (e. to enter the thorax.g. The cardiac branches o f CN X (cardiac nerves) also originate in the neck and thorax (Fig. On the right side. C4. C l segment) that are severe enough to cause paralysis . 224). angle between and posterior to the internal jugular vein and carotid artery. On the left. but on the right. which is about 30 cm long. The Phrenic Nerve (Figs. After looping. 1-42). 8-26. 8-31.Figure 8-31. CN X crosses the origin of the subclavian artery. 8-33) and run along the arteries to the arch of the aorta and the cardiac plexuses of nerves (see Figs. As the developing diaphragm migrates caudally. 1988). It arises chiefly from the fourth cervical nerve (with contributions from C3 and C5). both recurrent laryngeal nerves pass superiorly to reach the posteromedial aspect of the inferior pole of the thyroid gland. During the fifth week of development. and 8-34. and C5 grow into the septum transversum. 8-29. it lies on the scalenus anterior muscle that covers the second part of this artery. see also Fig. deep to prevertebral fascia and the transverse cervical and suprascapular arteries. The recurrent laryn­ geal nerve.. where they ascend in the tracheoesophageal groove to supply all the intrinsic muscles of the larynx except the crico­ thyroid (Table 8-6). Dissection of the left side of the root of the neck. at the level of the superior border of the thyroid cartilage and super­ olateral to the internal jugular vein. This nerve. 1-68. is the sole motor nerve to the thoracic diaphragm (p. it carries the phrenic nerves with it. showing the deep cervical lymph nodes and the termination of the thoracic duct (see also Fig. posterior to the brachiocephalic vein and the sternoclavicular joint. The phrenic nerve is formed at the superior part of the lateral border of the scalenus anterior muscle. the primordium of the central tendon of the diaphragm when it is in the cervical region. the phrenic nerve crosses the first part of the subclavian artery. It descends obliquely with this vein across the scalenus anterior muscle.

8-11 and 8-12) occurs in 20% to 30% of persons. If an accessory phrenic nerve is present. It is frequently derived from C5 as a branch of the nerve to the subclavius muscle. and inferior). of the upper limbs have little effect on breathing because the phrenic nerves arise from more cranial segments (C3.g. 8-28.g. To produce temporary therapeutic paralysis of one half the diaphragm (e. just anterior to the angle between the trachea and esophagus. a phrenicotomy is performed during which the phrenic nerve is sectioned. and C5). Breathing would not be normal however. Severance o f a phrenic nerve in the root of the neck (or elsewhere) results in paralysis of the corresponding half of the diaphragm. Note the recurrent laryngeal nerve ascending beside the trachea. the fibers of which k the spinal cord in the ventral roots of thoracic spinal nerv es ? Fig. anc 1 34). The S ym pathetic Trunks (Figs. Dissection of the left side of the root of the neck. It is usually fjs t . The Inferior Cervical Ganglion (Figs. C4. 8-31). In other cases. An accessory phrenic nerve (Figs. internal jugular vein.g. (e. the phrenic nerve is crushed with a hemostat for up to 1 cm of its length. 8-21 and 8-22). p. 30).. 8-30. fibers cervical structures as postganglionic fibers in cervical spinal ner or leave as direct visceral branches (e. 8-26. where it is wrapped ar : _~ the posterior aspect of the vertebral artery. Observe the conic of the carotid sheath (see also Figs. especially the i n l ­ and external carotid arteries. anc * 32).. 8-26. These longitudinal strands of autonomic nerve fibers ¿7 their associated sympathetic ganglia are located in the neck _ terolateral to the vertebral column from the level of the f. a phrenic nerve block is sometimes done. to the thyroid glanc Branches to the head run with the arteries. The anesthetic solution is injected around the phrenic nerve where it lies on the anterior surface of the middle third of the scalenus anterior muscle. middle. for several months after the surgical repair of a dia­ phragmatic hernia). cervical vertebra. These trunks receive no \vhite rami com* * nicantes in the neck.814 Clinically Oriented Anatomy rior constrictor External laryngeal nerve Superior thyroid artery and vein Thyroid cartilage Sympathetic trunk Cricothyroid Cricoid cartilage----------Contents of carotid sheath (common carotid artery. section or crushing of the phrenic nerve will not produce complete paralysis of the cor­ responding half of the diaphragm. It lies lateral to the main phrenic nerve and usually joins it in the root of the neck or in the superior part of the thorax. a phrenic nerve crush may be performed. because the intercostal muscles would be paralyzed. to interrupt a severe case of hiccoughs [spasmodic sharp contractions of the diaphragm]). This collection of nerve cells lies at the level of the super border of the neck of the first rib. but they contain three cervical sym pathe: ganglia (superior. vagus nerve) Ascending cervical branch Inferior thyroid artery Inferior thyroid vein Thoracic duct Esophagus Recurrent laryngeal nerve Trachea Sternothyroid Anterior sternoclavicular Articular disc Figure 8-32. From these sympathetic trunks.. In such cases. about 3 cm superior to the clavicle (Fig. These ganglia rece their preganglionic fibers from the superior thoracic spinal ner*: through white rami communicantes. 8-30. To produce a longer period of paralysis of half of the diaphragm. 26.

or any other abdominal organ. which keep the trachea patent. 1-72 whereas on the left side.816 Clinically Oriented Anatomy Sternohyoid Sternothyroid [ Vocal told (cord) Roof of infraglottic region [ Fascial band I Recurrent laryngeal nerve Middle thyroid vein Sternocleidomastoid Platysma Common c a r o : : a* I Internal jugula' Left vagus ne*v? Omohyoid Omohyoic Lymph nodes Scalenus anterior Brachial plexus Left phre~ k nerve Inferior cervical ganglion Scalenus medius Vertebral vein and artery Longus colli Inferior thyroid artery Esophagus Retropharyngeal space C6 and C5 Figure 8-34. 77). forming metastases (new malignant tumors).g. 2-34). The esophagus is also discussed in Chapter 2 (p. Blockage o f the thoracic duct (e. and (3) a deep alimentar layer containing the pharynx and esophagus. from an abdominal cancer) through the thoracic duct into the root of the neck. It drains lymph from the entire body. the thoracic duct lies between the pleura and the esophagus (see Fiz 1-73). 24. The trachea extends fro m the larynx to the roots o f the lungs. which empties into the venous system at or near the junction of the right internal jugular and right subclavian veins. layer containing the larynx and trachea. except the right side of the head and neck. The cancer cells proliferate here. the posterior wall of the trachea is flat. Observe that the thyroid gland is asymmetrically enlarged. 8-40) and enc? at the cardiac orifice of the stomach (see Fig. the esophagus is in contaa: with the cervical pleura at the root of the neck (see Fig. The Esophagus This thick. On the right side. The lymph apparently enters the ven­ ous system through other lymphatic channels. Hence. a distance oi about 12 cm (see Fig. 8-21. Transverse section of the neck at the level of C7 vertebra. and 8-34: sr= also Fig. Some tumor cells enter the venous system and others extend by retrograde permeation into the inferior deep cervical lymph nodes or supraclavicular nodes. Malignant tu­ mor cells pass (e. 8-35 The Cervical Viscera The cervical viscera are disposed in three layers (Figs. 8-21 and S34). 160» The Trachea The trachea (windpipe) is a fibrocartilaginous tube that is supported by incomplete cartilaginous tracheal rings. and thymus glands. 1-25). and the right side of the thorax (Fig.. 8-21 nd 8-34): (1) a superficial endocrine layer containing the thyid. the right upper limb. stomach. 25). thoracic duct enters the left brachiocephalic vein at the junction of the subclavian and internal jugular veins. The isthmus of the thyroid glanc usually lies over the second and third tracheal rings (Figs. p. a vessel 1 to 2 cm long. are deficient posteriori} where the trachea is related to the esophagus (Figs. The supraclavicular nodes. parathyroid. partic­ ularly on the left side. 8-29. These areas drain through the right lymphatic duct.g. distensible muscular tube extends from the phar­ ynx to the stomach (about 25 cm). posterior to the subclavian artery. may be enlarged when there is a carcinoma of the bronchus (p. 4-26). (2) a middle respiratory . It begins in the median plam at the inferior border of the cricoid cartilage (Fig. These rings. It lies between the trachea and the anterior longitudinal ligament e the surfaces of the vertebrae (Figs. by tumor cells) usually produces no symptoms..

In this specimen there is an accessory thyroid gland on the right. lateral to the thyroid cartilage. reflected External laryngeal nerve | Superior thyroid a rte ry ! Thyrohyoid Sternocleidomastoid branch Cricothyroid Superior thyroid vein Sternothyroid Middle thyroid vein Thyroid gland Internal jugular vein Vagus nerve Common carotid artery Subclavian arte Sternohyoid. reflected Inferior thyroid vein— Brachiocephalic trunk Figure 8-36. Dissection of the anterior aspect of the neck. lying on the thyrohyoid muscle.818 Clinically Oriented Anatomy Nerve to thyrohyoid Internal laryngeal nerve External carotid artery Sternohyoid. .

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