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NECK: GENERAL
HISTORY
The anatomic and surgical history of the general neck, thyroid, parathyroids, trachea, and salivary glands is shown in Table 1-1.
Table 1-1. Anatomic and Surgical History of the Neck, Thyroid, Parathyroids, Trachea, and Salivary Glands
Egypt

2780- Statues show signs of Graves' disease
2280
B.C.

India

2000- The Hindu Rig Veda mentions tracheal cannulation
1000
B.C.

China

1600
B.C.

Used burnt sponge and seaweed to treat goiters

Sushruta

600
B.C.

Introduced the nasolabial flap

India

400
B.C.

The Ayur Veda discusses the treatment and diagnosis of goiters

Egypt

69-30 A temple wall engraving shows Cleopatra with goiter
B.C.

Celsus

50-30 Described the appearance and surgery of cystic goiters
B.C.

Galen (ca. 130200 A.D.)

Considered the thyroid a buffer between the heart and the brain. Called the thyroid cartilage thyreos, meaning "oblong shield."

Paul of Aegina
(625-690)

Surgically treated a bronchocele. Attributed parotitis to humoral imbalance in the head (collecting in the parotid gland during fevers, for
example).

Ali-ibn-Abbas

ca.
990

Reported on the surgical treatment of goiters

Abul Casen
Ebn Abbas
(Albucasis)

1050

Treated "elephantiasis" of the throat (goiter) surgically and stopped hemorrhage using Khalaf cautery and ligatures

Wang Hei

1475

Described the thyroid gland while recommending that dried thyroid be used to treat goiter

da Vinci (14521519)

Provided illustrations of the thyroid glands

Paré (1510-

Described the parotid glands as "emunctories of the brain"

1590)
Vesalius

1543

Wrote of and illustrated the "Glandes laryngis radici adnatae" (thyroid glands) in Fabrica

Eustachius

1563

Described the connection point of the two thyroid lobes as an "isthmus"

Severino
(1580-1656)

Performed a tracheotomy to open an obstructed airway. Constructed a trocar to maintain air passage after the procedure.

Casserio

1601

Described the thyroid glands, calling them "the glands of the larynx"

Fabricius

1620

Thought of a goiter as an enlargement of the thyroid glands

Feyens

1649

Performed a tracheotomy, calling it a "bronchotomy"

Wharton

1656

Used the term "thyroid" correctly in his Adenographia. He believed that it served to lubricate, drain, and warm the larynx.

Hesiter (16831758)

Established the term "tracheotomy," and provided the first description of surgical excision of goiter

Von Haller

1743

First to describe a carotid body tumor

Duphenix

1757

Wrote of gustatory sweating in the Memoirs de L'Academie Royale de Chirurgie

Gooch

1773

Reported two thyroidectomies

Von Haller

1776

Classified the thyroid, thymus, and spleen as glands without ducts that release their fluids into the bloodstream

Parry

1786

Offered an original account of exophthalmic goiter

Desault

1791

Reported a successful excision of part of the thyroid

Blizzard

1811

Successfully ligated the superior thyroid arteries, offering another form of thyroidectomy

Coindet

1820

Recommended iodine as a treatment for goiter

Parry

1825

In a posthumously published paper (d. 1822), he first described the effects of "thyrotoxicosis" — now known as Graves' disease (in England)
and Basedow's disease (in Europe)

Graves

1835

Observed and described effects of an overactive thyroid

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Owen

1852

Described the parathyroid gland of a rhinoceros

Buck

1853

Performed a partial laryngectomy

Lushka

1862

Described carotid body tumors in great detail

Czerny

1870

Performed laryngectomies on 5 dogs (4 died)

Gull

1873

Described primary myxedema

Billroth

1873

As reported by Gussenbauer in 1874, he performed a laryngectomy

P. Von Bruns

1878

Argued, "The attempt at radical extirpation of cancer of the larynx by means of thyrotomy has proved itself completely unsatisfactory and
worthless."

Reigner

1880

Attempted excision of a carotid body tumor

Sandström

1880

Described the parathyroid glands, suggesting they were embryonic portions of the thyroid

Rehn

1880

Performed a thyroidectomy to treat exophthalmic goiter

Steida

1881

Described thyroid development

Billroth

1881

Reported 48 thyroidectomies performed since 1877, in which only four patients died. First to use artery forceps to prevent and stop
hemorrhage. Noted the presence of post-surgical tetany in many of his patients.

Kocher

1883

Reported his first 100 thyroidectomies (30 of which were total thyroidectomies). Method involved ligating the thyroid arteries outside the
capsule and the gland with an aneurysm needle, and ligating as close to the carotid artery as possible. Used a transverse collar incision now
bearing his name. Noted the presence of "cachexia stermipriva" or postoperative myxedema in his total thyroidectomy patients.

Born

1885

First used term "lateral thyroid"

Von MikuliczRadecki

1886

Described and performed subtotal thyroidectomy to avoid complications arising from removal of the gland

Maydl

1886

Successfully removed a carotid body tumor. The patient suffered a postoperative stroke, causing hemiplegia and aphasia, and later died.

Horsley

1886

Observed nervous system depression after thyroidectomy in monkeys. Concluded that the thyroid secreted a vital substance.

M. Mackenzie

1887

Opposed total laryngectomy in the case of Emperor Frederick II of Prussia

Von MikuliczRadecki

1888

Reported a case in which the patient experienced sweating involving submandibular (submaxillary) and parotid gland swelling (later named
Mikulicz' disease)

Albert

1889

Successfully removed a carotid body tumor without postoperative stroke

Von
Recklinhausen

1891

Observed and described osteitis fibrosa cystica in hyperparathyroidism

Gley

1891

Described tetany following removal of the parathyroid glands during thyroidectomy

Kocher

1895

Reported 900 cases of thyroidectomy with a mortality rate slightly higher than 1%. Avoided total thyroidectomies whenever possible.

1898

Reported an additional 600 thyroidectomies with only 1 operative death (caused by anesthesia).

Vassale and
Generali

1896

Introduced the term "parathyroid"

Butlin

1900

Advocated clearing out the anterior triangle of the neck (especially its lymphatic component) to combat the spread of metastatic disease from
the tongue

Loeb

1901

Observed occurrence of tetany in frog muscle deprived of calcium

M. Askanazy

1903

Hypothesized on the relation between parathyroid tumors and osteitis fibrosa cystica

C. Mayo

1904

Presented a paper on thyroid surgery to the American Surgical Association. Reported 40 cases of Graves' disease that were treated by
thyroidectomy.

Erdheim

1906

Studied the relationship between parathyroid glands and calcium metabolism, noting compensatory hypertrophy and osteomalacia

Halsted

1906

Provided dietary supplements of parathyroid glands from cattle to confront clinical tetany. Experimented with transplantation of the
parathyroids.

Crile

1906

Reported on 132 cases in which he performed a radical neck excision. Procedure included en-bloc resection of the regional lymph nodes,
sternocleidomastoid muscle, internal jugular vein, and submandibular (submaxillary) salivary gland.

C. Mayo

1907

First to use the term "hyperthyroidism"

MacCallum and 1908
Voegtlin

Studied hypoparathyroidism and its relation to low serum calcium. Found that injecting calcium relieved tetany.

C. Jackson

1909

Performed the first modern tracheostomy

C. Mayo

1912

Operated on 278 patients with exophthalmic goiter without a death. Recommended the division of the strap muscles for adequate exposure
(visualization of the recurrent laryngeal nerve) and for the preservation of the parathyroids to decrease the risk of tetany.

Kendall

1914

Isolated thyroxine

Schlagenhaufer 1915

Found that a tumor, not compensatory hypertrophy, is present in osteitis fibrosa cystica. Recommended the excision of parathyroid tumors.

Lipsztat

1922

Observed gustatory sweating near the parotid gland

L. Frey

1923

Published article on auriculotemporal nerve syndrome involving the parotid gland. The disease was later named Frey's syndrome.

Hanson

1924

Extracted parathyroid hormone

Mandl

1925

Removed a parathyroid adenoma

Harington

1926

Determined the chemical structure of thyroxine

Collip

1926

Linked hyperparathyroidism to elevated serum calcium (also isolated parathyroid hormone in 1925)

DuBois

1926

Removed a parathyroid adenoma – finally found in the mediastinum after seven previous explorations – in a patient with osteitis fibrosa
cystica due to hyperparathyroidism

Harington and
Barger

1927

Synthesized thyroxine

Weller

1933

Believed that 3 primordia are responsible for thyroid genesis ("lateral thyroid primordium")

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Gilmour

1938

Published his studies on the gross and histological anatomy of the parathyroid glands

Hyde

1944

Reported on the total removal of a cervical thymic cyst

Ramsay

1950

Transplanted and cultured the 4th pharyngeal apparatus; was not able to produce thyroid tissue, but produced parathyroid and thymic tissue

Wendlet

1950

Synthesized cortisol

Martin

1951

Published Neck Dissection, which outlined his experiences with prophylactic neck dissection as a treatment for cervical cancer

Gross and Pitt- 1953
Rivers

Extracted triiodothyronine from the thyroid gland. Later synthesized it as liothyronine.

Redon

1955

Published his classic report on the surgery of the salivary glands

Martin

1957

Published his classic work, Surgery of Head and Neck Tumors

Patey,
Thackray, and
Keeling

1965

Published an extensive report describing the behavior of salivary gland tumors and their treatment

Pearse

1966

Renamed the interfollicular cells the "C" cells because of their calcitonin-producing properties

Toye and
Weinstein

1969

Established the concept of minimally invasive airway access for surgery

Beahrs

1977

Detailed technique and surgical anatomy of radical neck dissection

Conley and
Clairmont

1977

Described the use of the scapula flap for reconstruction

Futrell et al.

1978

Described platysma myocutaneous flap use in neck reconstruction

Ariyan

1979

Described the use of the pectoralis major myocutaneous flap in neck reconstruction

Panje et al.

1987

Described gastroomental flap use in neck reconstruction

Gaz

1987

Noted the unusual location of parathyroid glands in surgical patients

History table compiled by David A. McClusky III and John E. Skandalakis.
References:
Albright F. A page out of the history of hyperparathyroidism. J Clin Endocrinol 1948;8:637-657.
Ariyan S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979;63:73-81.
Beahrs OH. The surgical anatomy and technique of parotidectomy. Surg Clin North Am 1977;57:477.
Beahrs OH. Presidential Address: Lest we forget. Surgery 1987;102:893-897.
Becker WF. Presidential Address: Pioneers in thyroid surgery. Ann Surg 1977;185:493-504.
Burton MJ, Brochwicz-Lewinski M. Lucja Frey and the auriculotemporal nerve syndrome. J Roy Soc Med 1991;84:619-620.
Cady B. History of thyroid and parathyroid surgery. In: Cady B, Rossi RL (eds). Surgery of the Thyroid and Parathyroid Glands (3rd ed). Philadelphia: W.B. Saunders,
1991. pp. 1-4.
Colcock BP. Lest we forget: A story of five surgeons. Surgery 1968;64:1162-1171.
Conley JJ, Clairmont AA Jr. Regional flaps in ablative surgery in the head and neck. Am Fam Physician 1977;15:100-105.
Futrell JW, Johns ME, Edgerton MT, Cantrell RW, Fitz-Hugh GS. Platysma myocutaneous flap for intraoral reconstruction. Am J Surg 1978;136:504-507.
Givel JC. Historical review. In: Givel JC (ed). Surgery of the Thymus: Pathology, Associated Disorders and Surgical Technique. Berlin: Springer-Verlag, 1990, pp. 1-8.
Gray SW, Skandalakis JE, Akin JT Jr, Droulias C, Vohman MD. Parathyroid glands. Am Surg 42(9):653-656, 1976.
Ioannides C, Fossion E. Nasolabial flap for the reconstruction of defects of the floor of the mouth. Int J Oral Maxillofac Surg 1991;20:40-43.
Liapis C, Gougoulakis A, Karydakis V, Verikokos C, Doussaitou B, Skandalakis P, Gogas J, Sechas M. Changing trends in management of carotid body tumors. Am Surg
1995;61:989-993.
McIntosh D. Surgical interests in some anomalies of the cervical viscera. J R Coll Surg Edinburgh 1979;24(4):191-204.
Martin H. Surgery of Head and Neck Tumors. New York: Hoeber-Harper, 1957, pp. 3-13.
Martin H, Valle BD, Ehrlich H, Cahan WG. Neck dissection. Cancer 1951;4:441-499.
Nelson WR. In search of the first head and neck surgeon. Am J Surg 1978;154:342-346.
Pahor AL. Historical article: Ear, nose and throat in ancient Egypt. J Laryngol Otol 106:863-873, 1992.
Panje WR, Little AG, Moran WJ, Ferguson MK, Scher N. Immediate free gastro-omental flap reconstruction of the mouth and throat. Ann Otol Rhinol Laryngol
1987;96:15-21.
Ramsay AJ. Experimental studies on the developmental potentialities of the third pharyngeal pouch in the mammalian embryo (mouse). Anat Rec 1950;106-234.
Schwartz SI. Little glands, big names (editorial). Contemp Surg 1993;42:402.
Wilkins EW Jr. Thymoma. In: Pearson FG, Deslauriers J, Hiebert CA, McKneally MF, Ginsberg RJ, Urschel HC (eds). Thoracic Surgery. New York: Churchill Livingstone,
1995, p. 1419.
Wilkins EW Jr. Thymectomy. In: Pearson FG, Deslauriers J, Hiebert CA, McKneally MF, Ginsberg RJ, Urschel HC (eds). Thoracic Surgery. New York: Churchill Livingstone,
1995, p. 1483.

EMBRYOGENESIS OF THE NECK

Normal Development
The neck, as seen in the adult human, does not exist in the embryo. The embryogenesis of the region is that of the organs contained within it: chiefly the
pharynx and its derivatives, the thyroid, parathyroid, and thymus gland (the last is also considered part of the superior mediastinum). In addition, vessels
passing through the neck from the head to the thorax are elongated and modified during the course of development.
The pharynx elongates at 5 weeks and the esophagus elongates later. After the diaphragm has descended, these three structures separate the head of the

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From this stage on. mesodermal branchial arches. with permission. and branchial membranes (closing plates). Fig. Seventh week. Further details of differentiation and migration will be discussed in the chapters on the specific organs. Branchial arches are reduced. thyroid gland. C. Neck The pharynx elongates at 5 weeks and the esophagus elongates later. and the unpaired ventral floor between them. Prominent branchial arches mark the site of the neck. Rowe JS Jr. they do not communicate with the clefts. After the diaphragm has descended. Gray SW. B. Fifth week. The embryogenesis of the four arches starts in the fourth and fifth weeks. Characteristically.htm 4/125 . these three structures separate the head of the developing embryo from the relatively large heart.uni-plovdiv. 1-1). A. Each lateral branchial apparatus is formed by endodermal pouches. which are formed by the ectoderm and endoderm (Figs. as well as their phylogenetic significance. By 7 weeks. larynx. The unpaired floor is of endodermal origin and produces the tongue. New York: McGraw-Hill. 1-2. or closing plates. The development of the neck. a constriction appears between head and thorax. the true neck is present. the pharyngeal pouches develop internally. At the same time. ectodermal branchial clefts. Fig. (Modified from Skandalakis JE. 1-2. They are marked externally by the four ectodermal branchial or pharyngeal clefts on each side. http://web. Twelfth week. The bridges between the arches are the branchial membranes. 1-3). 1-1.5/24/2014 Print: Chapter 1. a neck is visible (Fig.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. The embryonic pharynx consists of a lateral branchial apparatus on each side. and trachea. 1983. Anatomical Complications in General Surgery.) We present a very brief description of the pharyngeal apparatus to help the student understand clinically applicable accounts of the autogenic origin of the many anatomic entities of the neck.

H. 1973. Neck Drawings illustrating the human branchial apparatus. 1-3. and a muscular component.htm 5/125 . Lateral views. an artery. I.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. showing later development of the branchial arches. Dorsal view of the cranial part of an early embryo. Transverse section through the cranial region of an embryo. illustrating the branchial arch components and the floor of the primitive pharynx. B to D. Philadelphia: WB Saunders. (Based on Moore KL.5/24/2014 Print: Chapter 1. Horizontal section through the cranial region of an embryo. Facial views. J. a nerve. illustrating the relationship of the first arch to the stomodeum or primitive mouth. E to G. illustrating the branchial arch components and the floor of the primitive pharynx. A. http://web. Sagittal section of the upper region of an embryo. The Developing Human: Clinically Oriented Embryology.) Fig. Each arch contains a cartilaginous component. illustrating the openings of the pharyngeal pouches in the lateral wall of the primitive pharynx.uni-plovdiv.

New York: McGraw-Hill. stylohyoid ligament. and closing plates.uni-plovdiv.htm 6/125 . – The second (hyoid) pharyngeal arch is responsible for the embryogenesis of the muscle of facial expression and for the styloid process. with permission. All the pharyngeal membranes (closing plates) disappear except the first one. (Modified from Brantigan OC. the upper and lower jaws. part of the hyoid bone. the stapes and stapedius muscle. Clinical Anatomy. stylohyoid muscle. and the cheek and lower eyelids. – The only muscle thought to be derived from the third (thyrohyoid or glossopharyngeal) pharyngeal arch is the stylopharyngeus. which remains as the tympanic membrane (eardrum). and the posterior belly of the digastric muscle. pharyngeal pouches.5/24/2014 Print: Chapter 1. Neck Branchial grooves.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Innervation is by the mandibular branch of the trigeminal nerve (V). Its nerve is the facial (VII). The pharyngeal arches: – The first (mandibular) pharyngeal arch is responsible for the embryogenesis of the muscles of mastication. and its blood supply is from the facial artery. branchial arches. It is innervated by the http://web.) Remember All pharyngeal grooves (clefts) disappear except the first one. which remains as the external auditory canal (external auditory meatus). and its artery is the external carotid. 1963.

between the internal and external carotid arteries. SURGICAL ANATOMY Surface Anatomy Landmarks The most prominent landmarks of the surface anatomy of the neck. – The fourth pharyngeal pouch: the dorsal part is responsible for the genesis of the upper parathyroids (parathyroids IV)..5 cm above the thyroid cartilage at the level of the third cervical vertebra. It is responsible for the embryogenesis of the cricothyroid muscle of the larynx. Small benign growths called cholesteatoma 2 in the form of thickenings of the endodermal lining of the middle ear develop and are said to commonly cause hearing losses. – For all practical purposes.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. to reach the skin. Variations in the site of division of the carotid artery will always be located above this point. DiGeorge syndrome) are secondary to partial or total agenesis of the parathyroid and thymus glands. – The fourth pharyngeal arch is unnamed. thyroid cartilage. the fifth pharyngeal pouch. (Note: At the midpoint of a line between the mastoid process and the thyroid prominence. Note: A persisting second plate opening can appear as a branchial cleft sinus. external and internal sinuses.g. and ductus arteriosus. the piriform recess is the site of the third pouch. the ventral part for the thymus. does not exist. and mastoid air cells (about 2 years of age). In 1993. A pharyngeal sinus or fistula typically travels from the pharyngeal wall. The cricoid cartilage forms the only complete cartilaginous ring around the airway. notoriously open into the tonsillar fossa. – The second pharyngeal pouch produces the palatine tonsils and the tonsillar fossa. right subclavian artery. Its nerve is the superior laryngeal branch of the vagus nerve. and perhaps the aortic arch. Remember Most pharyngeal fistulas and cysts originate from the second pharyngeal pouch and cleft. something that is not observed with the other cartilages of the respiratory system. The artery is the common carotid. The authors reported the case of a posterior cervical midline cystic hygroma." which is especially prominent in post-pubertal males. – The cricoid cartilage is located at the level of the sixth cervical vertebra. it is believed that they form normally in all embryos. While their origin is not fully understood. Anomalies of the first cleft are related to the facial nerve. http://web. mastoid antrum (about 9th month of gestation). – The third pharyngeal pouch: the dorsal part is responsible for the genesis of the lower parathyroids (parathyroids III). from above downward.5/24/2014 Print: Chapter 1. The bifurcation of the common carotid artery is located on the horizontal plane at this level.htm 7/125 . Congenital Anomalies Fistulas. Miller and Cohn 4 presented the 31st report of a fourth branchial pouch sinus. tympanic cavity. Pressure at this point will compress the common carotid artery. the following landmarks are noted: – The most prominent midline feature and the most readily palpated is the thyroid cartilage. tend to develop in the left posterior triangle. the greater horn of the hyoid bone can be palpated laterally.) – The arch of the cricoid cartilage is palpable just inferior to the thyroid cartilage. Neck glossopharyngeal nerve. are as follows: The sternocleidomastoid muscle separates the anterior part of the neck (anterior triangle) from the posterior part of the neck (posterior triangle). In the midline. Mesoderm of the sixth arch is responsible for the embryogenesis of the pharyngeal constrictors. – For all practical purposes. Thymic and parathyroid deficiencies (e. pulmonary arteries. The pharyngeal pouches: – The first pharyngeal pouch is responsible for the embryogenesis of the eustachian tube. like the fifth pharyngeal arch. pharyngeal muscles. The anterior tuberosity of the transverse process of the sixth cervical vertebra (carotid tubercle of Chassaignac) is located at the medial border of the sternocleidomastoid and at the level of the cricoid cartilage. and the laryngeal muscles. Its nerve is the recurrent branch of the vagus nerve. and appear early in life. In the adult pharynx. It is located between the third and fifth cervical vertebrae. and cysts are the result of obliteration of pharyngeal clefts and pouches. Gidvani and Bhowmick3 indicated that cystic hygromas are common congenital neck masses. especially in males. – The body of the hyoid bone can be palpated at about 1. the lateral portion of the trapezius muscle produces much of the fullness of the gentle curve that joins the lateral posterior part of the neck with the shoulder region. the "Adam's apple. – The sixth arch fuses with the fourth for the formation of the laryngeal cartilages.uni-plovdiv. In males with well-developed musculature. the fifth arch does not exist. Neck hygromas are congenital malformations of the lymphatic system of the neck. but occasionally some persist and proliferate to form these growths. the ventral part may be involved with a small amount of thymic tissue and with the ultimobranchial body. Fistulas of the second pouch open at the lower one-third of the medial border of the sternocleidomastoid (SCM) muscle.

Neck A horizontal plane approximately at the junction of the sixth and seventh cervical vertebrae can be associated with the following anatomic entities (Figs. 1-5. Clinical Anatomy. New York: McGraw-Hill. 1-4.) Fig. the fourth and fifth cervical vertebrae are at the level of the thyroid cartilage.htm 8/125 . 1-5. and the omohyoid muscle – entrance of the inferior laryngeal nerve (recurrent nerve) into the larynx – entrance of the vertebral artery into the transverse foramen of the sixth cervical vertebra and. Print: Chapter 1. the carotid sheath. with permission. 16. 1-4. and 1-7): – pharyngoesophageal junction – laryngotracheal junction – inferior thyroid artery (which is ventral to the middle cervical ganglion). which are located at the level of the seventh cervical vertebra Fig. The third cervical vertebra is at the level of the hyoid bone. (Modified from Brantigan OC.uni-plovdiv. slightly more inferiorly. the stellate ganglion – thyroid isthmus and the greatest height of the thoracic duct.5/24/2014 – The cricoid cartilage is located at the level of the sixth cervical vertebra. and then (in order). http://web.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. 1963.

New York: McGraw-Hill. (Modified from Brantigan OC. Clinical Anatomy. Seventh cervical vertebra. 1963.) Fig.5/24/2014 Print: Chapter 1. 1-6. Neck Sixth cervical vertebra.htm 9/125 . (Modified from Brantigan OC. Clinical Anatomy.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. 1963.) Fig. New York: McGraw-Hill. http://web.uni-plovdiv. with permission. with permission. 1-7.

(Modified from Anson BJ. with permission. Drainage of submental abscess. Generally speaking.) Fig.htm 10/125 .) Surgical Applications The consistency of cervical skin changes with age. Thyroidectomy. Proper placement of incisions in the neck paralleling the normal lines and creases of the skin. The surgeon selects the proper incision and its placement in relation to the underlying pathology. B. M. Excision of thyroglossal cyst or sinus. Philadelphia. Close the edges of the divided platysma muscle carefully. 1988.5/24/2014 Print: Chapter 1. However. Excision of carotid tumor or branchial cleft cyst. The orientation of the connective tissues of the dermis creates lines of tension in the skin. the vertical lines produce excellent exposure for surgery of the arteries. Combinations of vertical and transverse incisions can be used. E. Neck Diagrammatic cross section through the neck below the hyoid bone showing the layers of the deep cervical fascia and the structures that they envelop. if necessary. Skandalakis LJ. Drainage of cervical abscess at angle of jaw. http://web. G. the transverse incision is cosmetically superior to the vertical. with permission. Gray SW. since crossing the normal skin lines will produce a more prominent scar. In: Jamieson GG (ed). Cricothyreotomy. Remember. Surgical anatomy of the oesophagus. a superiorly-based apron flap should be used for neck dissection. Surgical Anatomy (5th ed). 1-9. Surgery of the Oesophagus. Tracheotomy. A. Excision of congenital sinus: partial mobilization here and lower segment at B1 . D. H. F. McVay CB. which are associated with skin creases of the body. L. 1-8. Fig. J. 1971. Saunders. I. C. known as the lines of Langer. Diverticulum of esophagus. Exposure of internal or external carotid arteries. Edinburgh: Churchill Livingstone.uni-plovdiv. and reapproximate the margins of the skin incision meticulously to lessen the likelihood of unsightly scarring from tension upon the skin. Exposure of common carotid artery. K. Hyperextension of the neck will give a better appreciation of the topography of the underlying structures in relation to the skin. (Modified from Skandalakis JE. Most of the commonly used incisions in the neck are presented in Figures 1-8 and 1-9. Exposure of brachial plexus or subclavian artery.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Scalenotomy or phrenic nerve interruption.

8 stated that selective management of penetrating neck injuries is safe and does not require routine diagnostic testing for asymptomatic patients with injuries in zones II and III. Although 31% underwent angiograms. Philadelphia: Lippincott-Raven. 309-317. (Modified from Strong EW. C. Brown. F. esophagus (38%). 2nd Ed. Neck exploration was performed in 81% of the patients and tracheostomies in 75% as well as repair of the http://web. Atteberry et al. Conley. Definitive care phase: neck injuries. only 13% showed vascular injuries.htm 11/125 .7 found physical examination alone to be safe and accurate for evaluation of vascular penetrating injuries in zone II of the neck. Martin. Eighty-one percent of the patients had injuries involving more than 1 major structure of the neck. A. (Modified from Jurkovich GJ. Morestin. Baker RJ (eds). that either high or low injuries can involve vessels where proximal and distal control is difficult. Latyshevsky and Freund. I. In Nyhus LM. B. pp. We quote from Bumpous et al.9 on penetrating injuries of the visceral compartment of the neck: Zone II of the anterior neck was the most commonly injured area. but they now refer to zones (Fig. Neck Selected incisions used for classic radical neck dissection.uni-plovdiv. Z. 1-10. Attie. However. 1992. middle. E. Zones of the neck. Boston: Little.5/24/2014 Print: Chapter 1. However. Surgery: Scientific Principles and Practice (2nd ed). MacFee. G.) In the same study cited above. Roon and Christensen stated correctly. Biffl et al. Zone II. Radical neck dissection. with the trachea (69%). Eckers and Byer. high. Mastery of Surgery. 1-10): Zone I is the area Roon and Christensen called "low". 1997. H. Barbosa. with permission. The junction of zones I and II is variously described as being at the cricoid cartilage or at the top of the clavicles.) Roon and Christensen 5 subdivided the areas of the neck into three regions with respect to injuries: – High (above the angle of the mandible) – Middle (between the angle and the bottom of the cricoid cartilage) – Low (below the cricoid cartilage) Surgeons continue to use Roon and Christensen's classification.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Zone III. In Greenfield LJ (ed). from an anatomic standpoint. Fig. and larynx (31%) the most commonly injured structures. with permission. D. The important implication of a zone I injury is the greater potential for intrathoracic great vessel injury. They advised immediate exploration. Roden and Pomerantz 6 also advised early operation (neck exploration) for penetrating wounds of the neck.

with permission. 1-12). Asensio J.21:41-48. Fig. 1-12. SW.htm 12/125 . 1-11). Berne TV. (From Britt LD. They presented an algorithm for the evaluation of these injuries (Fig. and esophagus (38%). gunshot wound. Fig. GSW. Belzberg H. Weaver F.5/24/2014 Print: Chapter 1.) Britt and Cole11 recommend a paradigm for penetrating neck injuries (Fig. controversial approach. Neck exploration was performed in 81% of the patients and tracheostomies in 75% as well as repair of the trachea (50%). Algorithm for evaluation of penetrating neck injuries. http://web. There is significant mortality associated with these injuries. HVI.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Penetrating neck injuries management guideline. Demetriades et al. *.10 concluded that physical examination and color-flow Doppler imaging are the diagnostic tools of choice for the physician. Velmahos G. Yellin A. Neck more than 1 major structure of the neck.and many of the patients have longterm sequelae such as dysphagia. For the evaluation of penetrating neck injuries. (From Demetriades D. 1-11. Evaluation of penetrating injuries of the neck: prospective study of 223 patients. stab wound. high-velocity injury.. hoarseness. Cole FJ.. and prolonged tracheostomy. larynx (31%). Theodorou D. World J Surg 1997. Cornwell E.uni-plovdiv.

SCM. and then by division of these into smaller triangular regions. 133:1177-1181. controversial approach. sternocleidomastoid muscle. beginning with the division of the neck into anterior and posterior cervical triangles. HVI.htm 13/125 . 1-14. gunshot wound. The anterior triangle of the neck is divided into four smaller triangles by the digastric and omohyoid muscles. Gray SW. stab wound. Neck Penetrating neck injuries management guideline. 1-13). The Anterior Cervical Triangle BOUNDARIES The boundaries are: Lateral: sternocleidomastoid muscle Superior: inferior border of the mandible Medial: anterior midline of the neck This large triangle may be subdivided into four more triangles: the submandibular. carotid. and submental (Fig. Rowe JS Jr. "Alternative" surgery in trauma management. GSW.) Topographic Anatomy of the Neck The topography of the neck lends itself to description by using a series of natural triangular areas.5/24/2014 Print: Chapter 1. *. (Modified from Skandalakis JE. muscular.45:590-596. http://web. Cole FJ. Fig. Am Surg 1979. Sarikcioglu et al. Surgical anatomy of the submandibular triangle.12 reported an anomalous digastric muscle with three accessory bellies and one fibrous band (Fig. Fig. high-velocity injury. with permission. Arch Surg 1998. 1-13. with permission. 1-14).bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.uni-plovdiv. SW. (From Britt LD.) SUBMANDIBULAR TRIANGLE The submandibular triangle is demarcated by the inferior border of the mandible above and the anterior and posterior bellies of the digastric muscle below.

intersecting the midpoint of a line between the angle of the mandible and the lowest part of the ear. it passes medial to the vein.htm 14/125 . Am Surg 1979. Near the end of the sixth week (slightly later than the parotid gland). Surgical anatomy of the submandibular triangle. becoming canalized later. nerves.) Remember The skin should be incised 4 to 5 cm below the mandibular angle.) The largest structure in the triangle. Fig. with permission. The first surgical plane of the submandibular triangle. It forms as a solid primordium. (Modified from Skandalakis JE. This.14 after studying 10 http://web. In such instances. passes lateral to the retromandibular (posterior facial) vein within the substance of the parotid gland in more than 90% of cases. starting from the skin. accessory belly. and the most frequent object of the surgeon's attention. posterior belly of digastric muscle. and muscles also are found in the triangle. First Surgical Plane: The Roof of the Submandibular Triangle The roof of the submandibular triangle is composed of skin. is the submandibular salivary gland. It must be noted that severe inflammation of the submandibular gland can destroy all traces of normal anatomy. Anomalous digastric muscle with three accessory bellies and one fibrous band. with permission. or surgical planes. Rowe JS Jr. Surg Radiol Anat 1998. will lie close to the position of the cervicofacial division of the facial nerve.uni-plovdiv. Demir S.20:453-454. fibrous band. For the surgeon.5/24/2014 Print: Chapter 1. Sindel M. it develops from the oral ectoderm. 1-15. The platysma and fat compose the superficial fascia.13 in others. the lower division of the facial nerve. Gray SW. superficial fascia enclosing the platysma muscle and fat. Several vessels. 1. The mandibular and cervical branches of the facial nerve arise from the cervicofacial division of the facial nerve.45:590-596. The platysma lies over the mandibular and cervical branches of the facial nerve. the contents of the triangle are best described in four layers. The mandibular (or marginal mandibular) branch of the facial nerve (VII) lies just below the angle. anterior belly of digastric muscle. Neck Schematic drawing of an anatomic anomaly. 1-15). A line drawn from the intertragic notch of the ear. 4. identifying and sparing the essential nerves becomes a great challenge. and the underlying mandibular and cervical branches of the facial nerve (VII) (Fig. Savary et al.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Oguz N. 3. 2. (Modified from Sarikcioglu L. superficial to the facial artery.

The descending branch innervates the platysma and communicates with the transverse cervical (C2. 1-17. Am Surg 1979. In a similar study. These measurements are shown in Fig. the deep layer of submaxillary fascia (deep cervical fascia). Skandalakis et al. From this position it ascends toward the angle of the lips so that anterior to the position of the facial artery it crosses the lower border of the mandible to supply the muscles of the corner of the mouth and lower lip." The mandibular nerve forms the first of such hammocks of the submandibular triangle. and proceeds to supply the quadratus labii inferioris muscle. Remember that the orbicularis oris and the muscles innervated by buccal branches actually raise the commissure on the affected side. Fig. the retromandibular (posterior facial) vein. The distance below the mandible is given in centimeters. 1-16. superficial to the facial artery.15 reported that the marginal mandibular branch of the facial nerve was single in 14 facial halves. (From Skandalakis JE. If the skin incision is placed at least 4 cm below the border of the mandible. wherein the facial vessels can be palpated. http://web. C3) cutaneous nerves of the neck. In 50 percent of the specimens. crosses the mandible superficial to the facial artery and vein. Basar et al. saw this hammock hanging so far below the mandible that a high transverse incision would have severed it. from superficial to deep. It is frequently confused with the mandibular hammock. found several marginal branches. The drooping is not noticeable when the mouth is in repose –only when it is in motion (smiling). Neck The mandibular (or marginal mandibular) branch of the facial nerve (VII) lies just below the angle. the mandibular branch was above the mandibular border and thus outside the boundaries of the submandibular triangle.) A study of Chinese adults demonstrated that in 67% the marginal mandibular branch ran above the lower border of the mandible. The curved course of this nerve and the similarly shaped courses of other nerves in this region have led to the term "neural hammocks.uni-plovdiv. The anterior branch. Savary et al. Dingman and Grabb17 found the branch to be above the border in 81 percent of their specimens. The nomenclature and topography of the branches of the facial nerve are confusing and variable.16 measured the distance between these two neural hammocks and the lower border of the mandible in 40 cadavers (80 cervicofacial dissections). Fig. Gray SW. and the hypoglossal nerve (XII) (Fig. the lymph nodes. consisted of two major branches in 24 facial halves. 1-17). Injury to the mandibular branch of the facial nerve results in a very slight drooping of the corner of the mouth. suggesting the existence of ethnic variations in the topography of the nerve branches. Surgical anatomy of the submandibular triangle. Depending on the nature of the injury.5/24/2014 Print: Chapter 1. Rowe JS Jr.htm 15/125 . and had multiple major branches in 2 halves. which can form a neural plexus around the facial artery. and joins the mandibular branch to contribute to the innervation of the muscles of the lower lip. The cervical branch of the facial nerve divides to form descending and anterior branches. In all individuals. This anterior branch forms the second neural hammock of the triangle. The neural "hammocks" formed by the mandibular branch (upper) and the anterior ramus of the cervical branch (lower) of the facial nerve. this branch crosses superficial to the facial vein within 2 cm beneath the angular notch of the mandible. Percentages indicate the frequency of the configuration in 80 dissections of these nerves. the drooping may be neuropraxia or permanent.45:590-596. part of the facial (external maxillary) artery. It lies between the platysma and the deep cervical fascia (general investing layer).14 after studying 10 fresh cadavers and 1 embalmed cadaver. with permission. even an exceptionally low cervical branch will not be accidentally cut. the ramus coli mandibularis. 1-16. particularly the intermediate ramus.18 Second Surgical Plane: The Contents of the Submandibular Triangle The structures of the second surgical plane. Skandalakis et al.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Cervicofacial Division of the Facial Nerve.16 The mandibular branch of the facial nerve always passes posterior to the angle of the mandible. the submental branch of the facial artery. are the facial (anterior facial) vein. The mandibular (marginal mandibular) nerve is usually the first branch of the cervicofacial division of the facial nerve. the superficial layer of submaxillary fascia (deep cervical fascia). C3) and great auricular (C2. Injury to the anterior cervical branch produces minimal drooling that will disappear in 4 to 6 months.

divides near the angle of the mandible into anterior and posterior divisions. emphasizing its importance in clinical and surgical anatomy. with permission. The third surgical plane of the submandibular triangle. isolate. which is derived from the superficial investing lamina of the deep fascia of the neck. and unite close to the angle of the mandible to form the common facial vein. it separates the parotid and submandibular glands.) The retromandibular vein. The ligament is a particularly thickened portion of the deep layer of the fascial capsule of the parotid.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. It can be ligated easily. a branch of the external carotid artery. Am Surg 1979. it is important to remember that the lymph nodes lie within the envelope of the submandibular fascia. extends from the styloid process to the angle of the mandible. Gray SW. (Modified from Skandalakis JE. with occasional extensions to the stylohyoid muscle and the posterior belly of the digastric muscle. it is under the submandibular gland. Surgical anatomy of the submandibular triangle. Third Surgical Plane: The Floor of the Submandibular Triangle The structures of the third surgical plane. Surgical anatomy of the submandibular triangle. Rowe JS Jr. with permission. Also. The anterior division passes forward to join the facial vein. Fig.uni-plovdiv. The common facial vein empties into the internal jugular vein near the greater cornu of the hyoid bone. and the anterior bellies of the digastric muscles and a major portion of the submandibular gland below. and its more http://web. its more posterior part inserts on the body of the hyoid bone. from superficial to deep. in close relationship with the gland.) Mylohyoid Muscle.5/24/2014 Print: Chapter 1. This ligament. always lying under the platysma. the middle constrictor muscle covering the lower part of the superior constrictor muscle. The mylohyoid arises from the mylohyoid line of the inner surface of the mandible. It must be ligated before it is cut to prevent bleeding after retraction. The posterior division joins the posterior auricular vein to form the external jugular vein. Am Surg 1979. enters the submandibular triangle under the posterior belly of the digastric muscle and under the stylohyoid muscle. (Modified from Skandalakis JE. Jovanovic 19 described this ligament. and part of the styloglossus muscle (Fig. After crossing the gland posteriorly.20 the mylohyoid muscles are considered to form a true diaphragm for the floor of the mouth. 1-18.13 It is necessary to remember that the facial artery pierces the stylomandibular ligament. the hyoglossus muscle. At its entrance into the triangle.45:590-596. thereby forming the common facial vein. Neck The second surgical plane of the submandibular triangle. clamp. The superficial portion of the gland has been removed and the deep portion is visible under the edge of the mylohyoid muscle. and that nodes occur along facial vessels (this is important in treating metastatic skin cancers). The facial vein and the anterior division of the retromandibular vein cross the triangle in front of the submandibular gland. Differentiation between glands and lymph nodes may be difficult. Gray SW.htm 16/125 . The facial artery. formed by the union of the superficial temporal and maxillary veins. It is wise to identify. with the geniohyoid muscle and the muscles of the tongue above. the artery passes over the mandible. Rowe JS Jr. which is inferior to the mandibular notch. include the mylohyoid muscle with its nerve.45:590-596. which most often is thick but sometimes is thin. According to DuPlessis. The superficial portion of the gland is exposed. and ligate both the facial vein and the anterior division of the retromandibular vein. 1-18).

Submandibular Space and Ludwig's Angina. and the submandibular ganglion (Fig. Intravenous therapy should be used to maintain fluid and electrolyte balances. the attachment of cervical fascia to the hyoid bone. are continuous at the posterior border of the mylohyoid. the hypoglossal nerve (XII). Surgical division of the fascia and mylohyoid is performed only for complications such as drainage of pus under tension. The sublingual and submaxillary spaces. Insertions are into the side of the tongue and at its inferior area. The left accessory mylohyoid muscle extended from the mylohyoid line of the mandible to the lower part of the mylohyoid raphe and hyoid bone. erosion of cervical vessels by the infectious process. The submandibular space can be thought of as the combination of the sublingual and submaxillary spaces. To avoid asphyxiation. Neck anterior part inserts with the opposite mylohyoid into the midline raphe between the hyoid bone and the mandible. 1-19). the lingual nerve. From this region. Infection of the submandibular space can spread posteriorly along the styloglossus muscle into the pharyngomaxillary space. Edema here. maintenance of an adequate airway is of utmost importance. The superior surface of the mylohyoid is in relationship with the lingual and hypoglossal nerves.22 the entire submandibular space is bounded tightly by the attachments of the cervical investing fascia to the mandible. Hyoglossus Muscle. Incisions invite additional foreign organisms into an area that frequently (and early) becomes gangrenous. which also supplies the anterior belly of the digastric. The hypoglossal nerve and its venae comitantes enter the floor of the mouth over the posterior edge of the mylohyoid. the hyoid bone itself. The origins are from the front area of the styloid process and from the stylomandibular ligament. include the deep portion of the submandibular gland. Fig. The middle constrictor originates from the angle between the lesser and greater horns of the hyoid bone and from the stylohyoid ligament. Fourth Surgical Plane: The Basement of the Submandibular Triangle The structures of the fourth surgical plane. The thin and quadrilateral hyoglossus muscle arises from the greater horn and body of the hyoid bone.uni-plovdiv. in Ludwig's angina (as urged by Lindner22): Cellulitic areas should not be incised. and with local treatment with massive hot compresses and hourly hot saline gavages to the oral cavity. and internal jugular vein thrombosis. The nerve to the mylohyoid. or basement of the triangle. with the highest ascending and overlapping the superior constrictor. the mucous membrane of the floor of the mouth. located between the anterior belly of the digastric and the normal mylohyoid muscles. The styloglossus muscle has two origins and two insertions. the sublingual gland. Cellulitis should be met with systemic treatment with specific antibiotic therapy.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. The fibers travel backward. Styloglossus Muscle. The uncinate part of the submandibular gland rounds the posterior border of the mylohyoid to lie in the connective tissue above it. the process can pass into the retropharyngeal space and then inferiorly into the superior mediastinum. These spaces can be involved in the diffuse inflammation (cellulitis) of Ludwig's angina. 1-19. Middle Constrictor Muscle. and the lowest fibers traveling down under the inferior constrictor. the submandibular duct arises and passes through the floor of the mouth to end at the sublingual caruncle beside the frenulum of the tongue anteriorly. the submandibular (Wharton's) duct. Remember. which often results from infections of the lower molar teeth. most commonly with streptococcus hemolyticus as the infectious agent. lateral to the hyoglossus. above and below the mylohyoid muscle. From its origin in the neck. Here.htm 17/125 .5/24/2014 Print: Chapter 1. the lingual artery passes deep to the hyoglossus muscle. the sublingual vein. Tracheotomy is imperative if the breathing becomes shallow and rapid. respectively. between it and the digastric. Its insertion is the median raphe. http://web. Sehirli and Çavdar21 reported a case of a left accessory mylohyoid muscle. The mylohyoid nerve lies on the inferior surface of the muscle. It enters the floor of the mouth between the hyoglossus muscle laterally and the genioglossus muscle medially. and the fascial investment of the posterior belly of the digastric. As noted by Lindner. and the swollen and displaced tongue can cause asphyxiation. arises from the inferior alveolar branch of the mandibular division of the trigeminal nerve. It ascends almost vertically into the side of the tongue between the styloglossus muscle laterally and the inferior longitudinal musculature of the tongue.

23 Lymphatic Drainage The lymph nodes of the submental triangle receive lymph from the skin of the chin. Neck The fourth surgical plane of the submandibular triangle. and the tip of the tongue. Rowe JS Jr. The contents of this triangle should be sacrificed in radical neck dissection.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. They send lymph to the submandibular and jugular chains of nodes. A few channels pass by way of the subparotid nodes to the spinal accessory chain. the oral cavity. and the anterior parts of the face.htm 18/125 . inferior constrictor of the pharynx. thyrohyoid muscle. Surgical anatomy of the submandibular triangle. and by removing its capsule and all surrounding tissue without.) The submandibular duct lies below the lingual nerve (except where the nerve passes under it) and above the hypoglossal nerve.uni-plovdiv. Efferent channels drain primarily into the jugulodigastric. longus capitus muscle Roof: investing layer of deep cervical fascia Contents The carotid triangle contains: bifurcation of the carotid artery internal carotid artery (no branches in the neck) branches of the external carotid artery – superior thyroid artery (rare) – posterior auricular artery – superficial temporal artery – internal maxillary artery – occipital artery http://web. The deep portion of the gland and duct are exposed.5/24/2014 Print: Chapter 1. CAROTID TRIANGLE Boundaries The boundaries are: Posterior: sternocleidomastoid muscle Anterior: anterior (superior) belly of the omohyoid muscle Superior: posterior belly of the digastric muscle Floor: hyoglossus muscle. The contents of the submandibular triangle are cleared out during radical neck dissection by removing the submandibular (submaxillary) gland and its envelope and lymph nodes within. Am Surg 1979. with permission. (Modified from Skandalakis JE.45:590-596. Lymphatic Drainage The submandibular lymph nodes receive afferent channels from the submental nodes. Gray SW. middle constrictor of the pharynx. jugulocarotid. SUBMENTAL TRIANGLE Boundaries The boundaries of this triangle are: Lateral: anterior belly of the digastric muscle Inferior: hyoid bone Medial: midline Floor: mylohyoid muscle Roof: skin and superficial fascia Contents The submental triangle contains lymph nodes. the lower lip. the floor of the mouth. and juguloomohyoid nodes of the chain accompanying the internal jugular vein (deep cervical chain).

Remember that occasionally the strap muscles must be cut to facilitate thyroid surgery. jugulocarotid. According to Beahrs.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. and cricothyroid muscles Contents The muscular triangle contains the thyroid and parathyroid glands. and the posterior deep cervical nodes. and juguloomohyoid nodes. strap. Neck – ascending pharyngeal artery – sternocleidomastoid artery – lingual artery (occasional) – external maxillary artery (occasional) – facial artery (occasional) tributaries of the internal jugular vein – superior thyroid vein – pharyngeal vein vagus nerve spinal accessory nerve hypoglossal nerve ansa hypoglossi cervical sympathetic trunks (partial) Protection of nerves and vessels. sternohyoid and sternothyroid muscles Roof: investing layer of the deep fascia. trachea. Read an Editorial Comment http://web. and removal of the lymphatic tissue is essential.5/24/2014 Print: Chapter 1. They should be cut across the upper third of their length to avoid sacrificing their nerve supply.uni-plovdiv. and sympathetic nerve trunk.23 this triangle is the least important. sternohyoid. the deep parotid nodes. Lymph passes to the supraclavicular nodes. Deep to the posterior belly. MUSCULAR TRIANGLE Boundaries The boundaries are: Superior lateral: anterior belly of the omohyoid muscle Inferior lateral: sternocleidomastoid muscle Medial: midline of the neck Floor: prevertebral fascia and prevertebral muscles. The posterior belly of the digastric muscle —which is between the submandibular and carotid triangles— is a reliable landmark in a dangerous area. the following anatomic entities will be found: internal and external carotid arteries internal jugular vein glossopharyngeal nerve (9th cranial nerve) spinal accessory nerve (11th cranial nerve) hypoglossal nerve (12th cranial nerve) sympathetic trunk Lymphatic Drainage Lymph is received by jugulodigastric. esophagus.htm 19/125 . and by nodes along the internal jugular vein from the submandibular and submental nodes.

New York: McGraw-Hill. Anatomical Complications in General Surgery. We will treat it as one entity.uni-plovdiv. levator scapulae muscle. Rowe JS Jr. 1-21) Inferior: clavicle Roof: superficial investing layer of the deep cervical fascia Floor: prevertebral fascia and muscles. splenius capitus muscle. Fig.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. 1983. 1-20).5/24/2014 Print: Chapter 1. http://web. with permission. and three scalene muscles Fig. 1-21. Posterior Cervical Triangle The posterior cervical triangle is sometimes considered to be two triangles —the occipital and the subclavian— which are divided by the posterior (inferior) belly of the omohyoid muscle (Fig. 1-20. (Modified from Skandalakis JE.htm 20/125 . Gray SW. The triangle may be divided into two smaller triangles by the omohyoid muscle. The posterior triangle of the neck.) BOUNDARIES The boundaries are: Anterior: sternocleidomastoid muscle Posterior: anterior border of the trapezius muscle (Fig. Neck Lymphatic Drainage Lymphatic drainage of the muscular triangle will be discussed with the thyroid gland.

There. Sacrifice the nerve if it is absolutely necessary.htm 21/125 . with lower mortality. the media is thin and poor in muscle. responding reflexively to changes in arterial pressure. The carotid sinus (Fig. and ipsilateral and secondary syncope. subclavian vein. phrenic nerve. 1-22) acts as a baroreceptor. accessory phrenic nerve. brachial plexus. Do not confuse the carotid sinus and the carotid body. inflammatory processes in the neck. Neck The floor of the posterior triangle. SURGICAL NOTES The following are surgical points to remember for the upper or occipital part of the posterior triangle: Clear the lymph nodes around the spinal accessory nerve very carefully.uni-plovdiv. receptors. Efferent vessels pass to a deep occipital lymph node (or occasionally to more than one node) which drains into deep cervical nodes along the spinal accessory nerve. such as Ludwig's angina. But the adventitia is thick. the carotid sinus is a dilated area that is usually located at the beginning of the internal carotid artery. cervical nerves. http://web. Variably deep within the triangle are the subclavian artery. they are far less common. because effective antibiotics arrest and cure the inflammation. LYMPHATIC DRAINAGE Superficial occipital lymph nodes receive lymph from the occipital region of the scalp and the back of the neck. Fig. Surgical Applications of the Cervical Triangles ANTERIOR TRIANGLE In the past. Anatomically. it is rich with elastic tissue. Elevation of pressure or compression of the carotid sinus can result in slowing of the heart rate. Although these inflammatory processes still occur.5/24/2014 Print: Chapter 1. 1-22. a sudden fall in arterial pressure. and lymph nodes. portions of the transverse cervical vessels. presented with severe mortality and morbidity. Surgical points for the lower or subclavian part of the posterior triangle: Be careful with the triangle's contents: the subclavian vein. and lymph nodes. and sensory nerve fibers from the glossopharyngeal nerve.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. spinal accessory nerve. CONTENTS Between the investing fascia and the prevertebral fascia are the accessory nerve (XI) and a portion of the external jugular vein. cerebral ischemia.

or hydrogen ion concentrations. The carotid body is a chemoreceptor which is sensitive to low levels of oxygen. perhaps due in part to the fact that the middle one-third of the clavicle is not protected by muscular attachments. Tumors of the carotid body may develop and present serious surgical problems.htm 22/125 . and sinusoids.5/24/2014 Print: Chapter 1. The carotid body (Fig. although it also seems to receive fibers from the vagus. Neck Diagram of the carotid sinus. Its nerve supply is derived principally from the glossopharyngeal nerve. the carotid bifurcation. http://web. It is composed of a fibrous capsule with septae which divide it into lobules composed of epithelioid glomus cells. One of the most common fractures is that of the clavicle. carotid body. and their innervation.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. The subclavius muscle does not have the power to protect the clavicle. Note that the carotid body lies not so much in. It responds to these by reflexively increasing respiratory ventilation via its connections with the brainstem. as medial to. POSTERIOR TRIANGLE The subclavian artery can be compressed against the first rib by pressure of the thumb placed in the supraclavicular fossa when the hand is grasping the neck. high levels of carbon dioxide. 1-22) is a tiny bilateral lobular anatomic entity 2 to 7 mm in size.24 It may be partially embedded in the carotid adventitia from which it developed embryologically. It is located at the carotid bifurcation or on the posterior medial side of the common carotid artery. What part the carotid branch of the vagus plays in this innervation is not known. supporting cells.uni-plovdiv. particularly with regard to hemorrhage during surgery.

In a few preparations. NOTE: At that point. We quote from Kierner et al. anterior to the internal thoracic artery and to the pulmonary hilum." The position of the accessory nerve in the posterior triangle can be ascertained as follows. Neck The accessory nerve (XI) divides the posterior triangle into two nearly equal parts. Second. First..27: The surgeon can feel the characteristic rounded anterior border of the scalenus anticus as he or she palpates through the fat and lymphoid tissue.5/24/2014 Print: Chapter 1. depending how far cranial in the neck it is identified. which would have indicated additional innervation.htm 23/125 . Posterior to the subclavian vein We quote from Kline et al. 1-23. Because this fascia is drawn distally as the axillary sheath upon the brachial plexus and axillary artery. The other landmarks cited in the literature..uni-plovdiv. This method avoids injury to the nerve with resultant wasting of the trapezius and drooping of the shoulder.25 we refer to the upper area as "carefree. make an incision just through the skin. The surgeon can clear down to the anterior border of the scalenus anticus with dispatch. (4) The SAN can easily be mixed up with the minor occipital nerve because the latter sometimes takes a similar course. we found that measuring at the posterior border of the sternocleidomastoid muscle from the clavicle provides the most reliable results and that the nerve can always be identified. During inspiration a fatal air embolism may take place. anesthetics injected into the sheath can affect the phrenic nerve. Scalene lymph node biopsy can produce iatrogenic pneumothorax or injury to the apex of the lung. emphasizes the exit of the greater auricular nerve along with cranial nerve XI. where the external jugular crosses the posterior border of the SCM. Posterior to the inferior belly of the omohyoid muscle.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Erb's point. such as the great auricular nerve or the sternocleidomastoid muscle itself.26 on the anatomy of the spinal accessory nerve (SAN) and the trapezius branches of the cervical plexus: (1) The SAN can be found medial as well as lateral to the internal jugular vein. – The subclavian artery and the brachial plexus can be compressed as they cross the first rib posterior to the anterior scalene muscle. it takes an S-shaped. The following are descriptions of the anatomic entities (from above downward) within the "careful" areas. Posterior to the internal jugular vein. If an abscess is present in this area. (2) When the SAN passes through the sternocleidomastoid muscle.. there are three topographic features in the vicinity of the supraclavicular triangle region of the "careful" part of the posterior triangle. A line drawn between the two points will lie over the course of the accessory nerve. turning upward just slightly medial to the anterior border of the trapezius muscle. – The spinal accessory nerve is closely related to the deep posterior cervical nodes. In this area. The crossing between these 2 important structures can happen only dorsally (44%) or ventrally (56%) to the internal jugular vein. the phrenic nerve enters the thoracic cavity. The cervical pleura and the apical parts of the lungs extend upward above the clavicle into the root of the neck. the supposed SAN must be followed right to the anterior border of the trapezius muscle to be sure that it keeps its craniocaudal direction. falls upon the shoulder. – The brachial plexus can be injured in the lower part of the triangle by such diverse means as stab wounds. excessive abnormal traction at childbirth. place a point on the anterior border of the trapezius one third of the distance between the acromion process and the back of the skull. – The phrenic nerve passes inferiorly on the ventral surface of the anterior scalene muscle beneath the covering of the prevertebral fascia. The external jugular vein passes downward from the area of the angle of the mandible to the middle of the clavicle. (3) The cervical plexus branches passing to the trapezius muscle are always subfascial because another relationship to the fasciae of the neck whether superficial or deep . This is an important clue. Remember.is anatomically impossible." and the lower area as "careful.If the nerve were followed through the muscle. 3-dimensional course instead of running straight through the muscle. place a point on the posterior border of the sternocleidomastoid. Furthermore. Use a hemostat to penetrate and drain the abscess. transverse cervical. or other sources of blunt trauma. a penetrating neck wound with division of the vein can allow air to be sucked into the vein because the deep fascia is fixed firmly to the venous wall. 1-24). Here the pericardiophrenic vessels are fellow travelers of the phrenic nerve. they were never found to branch within the muscle. the scalenus anticus can be divided after the surgeon has seen that the subclavian artery is free from its posterior surface. thereby missing the brachial plexus altogether. deep to the investing fascia. between the mediastinal pleura and the pericardium. show much more variability. in contradiction to some former works.Therefore. The interscalene groove and the supraclavicular fossa are present within the triangle... cutaneous branches of the posterior spinal nerves passed through the tendon plane between the spinous processes of the vertebral column and the trapezius muscle to reach the skin. very close to its intermediate tendon 2. knowing that the phrenic nerve is deep to the prevertebral fascia at this point. outside of the posterior triangle (Figs. Just above the clavicle. bullets. Borrowing from the terminology of Grant and Basmajian.. Posterior to the thoracic duct on the left neck 4. http://web. Once the phrenic nerve has been dissected free and guarded. thereby keeping the lumen of the vein open. the infraclavicular fossa is located just under the middle one-third of the clavicle.. and suprascapular arteries 3. two-thirds of the distance from the clavicle to the mastoid process. as well as injury to the highest part of the left thoracic duct. resulting in a hemiparalysis of the diaphragm. the vein pierces the investing fascia and drains into the subclavian vein. as well as some indications about their potential for injury. However..the communicating branch(es) with the cervical plexus would obviously be cut. Anterior to the subclavian artery 5. The topographic pathway and relations of the phrenic nerve with other anatomic entities in the neck: 1. as the novice tends to operate too far laterally and superiorly.

5/24/2014 Print: Chapter 1. The supraclavicular fossa.uni-plovdiv. and the jugular fossa. 1-23. Fig. http://web. Neck Fig.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. 1-24. the infraclavicular fossa.htm 24/125 .

and the anterior border of the trapezius muscle laterally. It is bounded by the pectoralis major. This is the pressure point of the subclavian artery. bounded by elements of the brachial plexus. The axillary vein appears deep to the skin. palpable hollow located inferior to the middle of the clavicle. http://web. B. muscle is relaxed. a triangle is formed by the clavicle inferiorly. The axillary artery. C. and the proximal one-half or one-third of the clavicle. The posterior scalene arises from the posterior tubercles of vertebrae C4-C6. – The Infraclavicular Fossa: The infraclavicular fossa is the soft. deltoid. A point located in such fashion in the middle of the triangle approximates the site of the passage of the subclavian artery and the emerging of the brachial plexus from between the anterior and middle scalenes. The apical and infraclavicular lymph nodes also are found in this fossa. is located deep to the axillary vein. which may be palpated between the finger and the first rib. The position of the cricoid cartilage can be used to approximate the level of the 6th cervical vertebra. and clavicle. The middle scalene muscle. A finger passed downward palpating in the interscalene groove will usually feel the pulse of the subclavian artery without difficulty. the groove between them can be palpated with varying ease. It inserts on the first rib between its tubercle and the subclavian artery groove. – Interscalene Groove: If the head is turned strongly to the opposite side. and clavipectoral fascia.htm 25/125 . anterior to the groove for the subclavian artery. The second part of the subclavian artery lies behind the anterior scalene muscle. scalenotomy alone may relieve this compression by allowing the vessel and nerves to drop forward.5/24/2014 Print: Chapter 1. A. It inserts upon the second rib. the anterior border of the trapezius. superficial fascia. Likewise. contraction of the anterior scalene muscle in the presence of a cervical rib can produce compression of the subclavian artery and brachial plexus.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. The anterior and middle scalenes lie in the floor of this triangle. Chassaignac's tubercle of the transverse process of C6 can be palpated just behind the posterior border of the sternocleidomastoid. arises from the posterior tubercles of the transverse processes of vertebrae C2-C7. the sternocleidomastoid muscle medially.28 – The Supraclavicular Fossa: The supraclavicular fossa is formed by the lateral (posterior) border of the sternocleidomastoid muscle. Neck Compression of the subclavian artery and brachial plexus. It descends almost vertically to insert on the scalene tubercle of the first rib.uni-plovdiv. The anterior scalene muscle arises from the ventral tubercles of the transverse processes of the 4th through the 6th cervical vertebrae. In different individuals. the largest of the three scalenes.

especially whiplash injuries. Patients with this problem can be treated with a combination of thrombolytic agents and anticoagulation. In such individuals. unrelated to intercurrent illness or iatrogenic manipulation." The topographic relations of the thoracic inlet: Posterior: First thoracic vertebral body Anterior: Superior border of the manubrium of the sternum Lateral: First rib We quote from Obuchowski and Ortiz31 on magnetic resonance (MR) imaging of the thoracic inlet: The borders of the thoracic inlet define an oblique plane that angles downward from the spine anteriorly to the first ribs.5/24/2014 Print: Chapter 1. (Modified from Harry WG.10:250-252. 1-25. scalenectomy is preferable to resection of the first rib.) The subclavian vein crosses the first rib ventral to the anterior scalene. MR's multiplanar imaging capacity allows the thoracic inlet to be subdivided into four distinct zones: visceral. resection of the first rib. It inserts upon the second rib. Sanders and Pearce32 observed that 86% of patients suffering from thoracic outlet syndrome had a history of some form of cervical trauma. Here the artery and nerves cross the first rib.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Harry et al. subclavian artery piercing the anterior scalene muscle belly. individuals thus affected have spontaneous or effort-related upper extremity axillary and subclavian venous thrombosis (Paget-von Schroetter syndrome). Clin Anat 1997. roots of C5 & C6 piercing the anterior scalene muscle belly. Perhaps the use of the word "outlet" is incorrect. Variations seen in relations between scalene muscles and the brachial plexus. Thoracic outlet syndrome actually refers to compression at the upper opening (inlet. Post-stenotic dilatation of the subclavian artery can be associated with the development of thrombi. Guha SC. The same authors observed the following variations: – The scalenus minimus muscle was present in 46 percent of instances (Fig. Neck posterior scalene arises from the posterior tubercles of vertebrae C4-C6. It is therefore best to consider the thoracic inlet as a region or "zone" which extends a short distance above and below this plane to include the lower portion of the infrahyoid neck and the upper portion of the superior mediastinum. or both. fascial bands. Scalene muscles and the brachial plexus: anatomical variations and their clinical significance.uni-plovdiv. with permission. compress the artery. where it is closely associated with. and often compressed by. pulmonary.29 reported that the commonly described anatomic relationship of the brachial plexus located between the anterior scalene and middle scalene muscles was found only in 60 percent of cases. the nerves. Accessory scalene musculature.htm 26/125 . Frequently. B. A. the subclavius muscle. 1-25) – In 15 percent of cases the anterior scalene muscle was penetrated by fused C5-C6 roots Fig. superior aperture).30 Thoracic outlet syndrome: The subclavian artery. can produce confusing symptoms similar to carpal tunnel entrapment of the median nerve. discharged distally into the artery. and balloon angioplasty. These thrombi. neurovascular. variably. and spinal. since the lower opening of the thorax is the true "outlet. This compression http://web. and can be subject to compression. or an atypical 7th cervical rib can. passes between the anterior and middle scalene muscles. in company with the brachial plexus and with contributions from cervical nerves C5-C8 and the 1st thoracic nerve. Bennett JDC.

scapula. cutaneous branches of the cervical plexus. muscle fibers change from a fast-twitch type 2 fiber to a hypertrophied slow-twitch type 1 fiber. In a study of 390 transaxillary resections of the first rib for arterial. and then normally regresses to its transverse process. and below to the clavicle. and 17 ribs exhibited abnormalities (7th cervical or atypical 1st thoracic). paresthesia or weakened pulses. In another study of patients suffering from thoracic outlet syndrome.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. It envelops two muscles —the trapezius and sternocleidomastoid— and two glands —the parotid and submandibular. the 7th cervical rib forms.htm 27/125 . (Modified from Skandalakis JE. Fig. trachea. About 67% of cervical ribs are bilateral. 55% had hypertrophy of the tendon of the subclavius muscle as well as enlargement of the insertion tubercle. they must first be ligated. Machleder et al. CT. In Makhoul and Machleder's33 study of patients suffering from Paget-von Schroetter syndrome. they do not retract. Neck Accessory scalene musculature. with permission.34 showed that there were demonstrable morphologic transformations of anterior scalene muscle fibers that reflect metabolic and enzymatic changes characteristic of various adaptive and pathologic processes. This compression results in scalenus anticus (anterior scalene) syndrome. 20 scalene muscles were supernumerary. variably. the nerves. It is composed of loose connective tissue. the platysma muscle. Paget-von Schroetter syndrome is frequently associated with thrombosis of the axillary-subclavian vein from exertion. and forms the roof of the anterior and posterior cervical triangles.35 even with early medical treatment complete resolution occurs in only 15% to 30% of patients." The condition develops as an abrupt swelling of the upper extremity. replaced by a major contribution from C4. http://web. 1983. compress the artery. attributable to traumatic stress and stretch injury. connective tissue. posteriorly to the spines and supraspinous ligaments of the cervical vertebrae. layer (surrounding the larynx. It forms two spaces —the supraclavicular and suprasternal. leading to the phrase "effort vein thrombosis. venous. Because of their attachment to the platysma above and the fascia below. with pain. and pharynx) – Prevertebral layer (posterior or deep layer) Superficial Fascia The superficial fascia of the neck lies beneath the skin. Anatomical Complications in General Surgery. the cervicofacial division of the facial nerve and small cutaneous blood vessels (Fig. 1-26 and 1-27) attaches above to the occipital and temporal bones and the mandible. 1-27. According to Flye. During development. the regressed part of the rib was often replaced by a fibrous band. The surgeon should remember that the cutaneous nerves of the neck and the anterior and external jugular veins are between the platysma and the deep cervical fascia. there is no space between this layer and the deep fascia. New York: McGraw-Hill. and manubrium of the sternum. When the C7 rib was incomplete.5/24/2014 Print: Chapter 1. In such changes. Variations in its fate vary from a fully formed rib to rudimentary forms associated with a fibrocartilaginous band. fat. Fasciae of the Neck The following classification of the rather complicated fascial planes of the neck follows the work of several investigators: Superficial fascia Deep fascia – Investing layer (superficial layer) – Middle. 1-26. Makhoul and Machleder33 found that 66% of the 175 patients had single or multiple abnormalities representing developmental variations: 86 scalene and 39 subclavius muscles were atypical in form or attachments.uni-plovdiv. The superficial fascia of the neck lies between the skin and the investing layer of the deep cervical fascia. If the veins are to be cut. 1-26). and the surgeon must guard against the possibility of production of an air embolism.) Deep Fascia INVESTING LAYER The superficial (investing) layer of the deep cervical fascia (Figs. fascial bands. Gray SW. or brachial plexus compression at the thoracic outlet. Rowe JS Jr. or an atypical 7th cervical rib can. bleeding from them can be serious. The presence of a cervical rib (found in about 1% of cases) often was shown to be indicative of a variation in the scalene musculature or in the brachial plexus where the first thoracic nerve had little input. Fig. or pretracheal. For all practical purposes. Such changes occur predominantly in young individuals in response to exercise. or both.

Note that the "danger space" and the retropharyngeal space show no interruption. Anatomy for Surgeons. (Based on Hollinshead WH.36 In keeping with the former view. http://web. but are continuous with the danger space and the retrovisceral space. 1-28) is sometimes described as investing the strap muscles anteriorly. merging with the superficial investing layer. these are "potential. Neck Fascial layers and spaces above the hyoid bone.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. 1-29). in a sagittal section." rather than "actual" spaces. Fig. 1. This layer is fixed to the thyroid and cricoid cartilages above.5/24/2014 Print: Chapter 1. respectively. 1-28.) PRETRACHEAL LAYER The middle (pretracheal) layer of the deep fascia (Fig. The attachment to the cartilages may be thickened to form the suspensory ligament of the thyroid gland (ligament of Berry). uniting with the superficial investing layer lateral to them. Conversely. 2nd Ed. below the level of the hyoid bone. 1968. it is also said to be a lamina that passes deep to the strap muscles. New York: Harper & Row. Note also that under normal circumstances.htm 28/125 . Vol.uni-plovdiv. forming the false capsule of the gland (Fig. it is said that a posterior layer of the pretracheal fascia envelops the thyroid gland.

1968. Vol 1: The Head and Neck. retrovisceral or retropharyngeal space between the prevertebral fascia and the pretracheal (visceral) fascial layers. Cross section. modified from Hollinshead. Study.htm 29/125 .uni-plovdiv. "danger space" within the prevertebral fascia. RV.5/24/2014 Print: Chapter 1. D. in longitudinal section. with permission. Skandalakis JE. Anatomy for Surgeons. 1-29. B. Clinical Gross Anatomy: A Guide for Dissection. and Review.) Fig.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. B. Neck Fascial layers of the neck. 1993. Pearl River NY: Parthenon. http://web. Chief fascial layers of the neck below the hyoid bone. From Colborn GL. A. New York: Harper & Row. (A.

and deep cervical lymph nodes. vagus nerve.5/24/2014 Print: Chapter 1. pretracheal. the prevertebral fascia divides to form a space in front of the vertebral bodies. Laterally. portion of the pretracheal fascia can be thought of as the visceral portion of this fascial layer. this fascial layer continues as buccopharyngeal fascia to the base of the skull. beneath the sternocleidomastoid muscle. 1-30. PREVERTEBRAL LAYER The prevertebral (posterior) layer (Fig. At its attachment to the transverse processes of the cervical vertebrae. the middle cervical fascia becomes ill-defined. It is continuous posteriorly with the buccopharyngeal and esophageal fasciae. In the upper part of the neck. and covers the cervical spine muscles. 1-28. or deep. the sheath becomes more adherent to the adventitial coverings of the carotid vessels and internal jugular vein. permitting an enlarging thyroid gland to extend posteriorly. including the scalene muscles and vertebral column anteriorly. Fig. the carotid sheath (Fig. http://web. the anterior layer being the alar fascia. 1-27) lies in front of the prevertebral muscles. It originates from the spinous processes and the ligamentum nuchae posteriorly." as the more appropriate name for the middle layer of deep cervical fascia. 1-30). Anteriorly. it contributes to the carotid sheath. as noted some time ago by Grodinsky and Holyoke. Posteriorly. This posterior.uni-plovdiv. it terminates inferiorly at about the level of the bifurcation of the trachea by blending with the alar part of the prevertebral fascia. and prevertebral— compose a fascial tube. the middle layer attaches above to the hyoid bone and below to the fibrous pericardium. Within this tube lie the common carotid artery. internal jugular vein.htm 30/125 .bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Posteriorly. the posterior layer retaining the designation of prevertebral fascia. Neck The anchor of the thyroid gland: the ligament of Berry. the connective tissue of the sheath blends with the fascial investments of the stylohyoid muscle and the posterior belly of the digastric.37 It is because of this continuity that some prefer the term "visceral layer" to "pretracheal layer. CAROTID SHEATH Three fasciae —investing. Fig. Above this.

It is considered in the chapter on the breast under the heading "Topographic Anatomy and Relations: Deep Fascia. Posteriorly. 1-27) is related to the anterior elements of the several peripharyngeal spaces. Neck Two views of the visceral compartment of the neck. 1-27) is continuous below with the visceral fascial covering of the esophagus. by direct perforations of the esophagus. Superiorly.uni-plovdiv. and submandibular spaces. 1-31." Spaces of the Neck There are many spaces in the neck that are defined by the fasciae (Figs. or by infections of the deep cervical lymph nodes which lie adjacent to it. it is fused with the first rib and Sibson's fascia. the carotid sheath is adherent to the posterior aspect of the sternum and clavicle and is lateral to the origins of the sternocleidomastoid and strap muscles.htm 31/125 . lateral pharyngeal. and masticator spaces. The lateral pharyngeal space (Fig. 1-27) which extends superiorly to the skull base and terminates inferiorly in the upper part of the thorax. Fig. Some others. Inferiorly. such as the parotid and submaxillary spaces. This space can be infected by descending infections. Buser and Bart39 studied the normal anatomy of the retropharyngeal space (Fig. the prevertebral fascia covers the scalene muscles and phrenic nerve. 1-27): this involves the posterior neck in toto from the base of the skull to the level of T1. The spaces are those related to the body of the mandible. As the sheath passes into the thorax. and provides origin for the axillary sheath. only those spaces that need special emphasis will be described. BUCCOPHARYNGEAL FASCIA The buccopharyngeal fascia (Fig. the visceral fascia passes on to the alar fascia of the carotid sheath. 1-28). Because this book is for the general surgeon. The potential danger space of Grodinsky and Holyoke37 (Figs. it is highly complex. In the root of the neck. muscular part of the prevertebral fascia. Behind the carotid sheath. The authoritative works on the cervical spaces are those of Grodinsky and Holyoke37 and Coller and Yglesias. http://web.36 AXILLARY FASCIA The axillary fascia takes its origin from the prevertebral fascia.5/24/2014 Print: Chapter 1. Peripharyngeal spaces include the retropharyngeal. The submandibular space (Fig. 1-31) is a lateral extension of the retropharyngeal space around the pharynx.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. continuing into the thorax to the fibrous pericardium of the heart and great vessels. parotid. It is joined rather loosely by delicate areolar tissue to the alar layer of the prevertebral fascia. will be discussed with the organs they are related to. T2 in the upper mediastinum in front of the prevertebral fascia and behind the buccopharyngeal or visceral fascia. it covers the posterior and lateral surfaces of the pharynx and continues forward over the external surface of the buccinator muscle of the cheek. The interval between the two fascial layers is the retropharyngeal space (Fig.38 Spaces above the Hyoid Bone Intrafascial spaces are formed by splitting of the several fascial layers of the neck. 1-27 and 1-28) lies between the alar component and the deeper. the connective tissue of the sheath separately encloses each structure within as they diverge from one another. 1-27. This space provides a plane for the spread of fluids or pathologic processes from the base of the skull to the thoracic diaphragm. and the submaxillary.

is secondary to tuberculosis or other osteomyelitis of a cervical vertebra. together with the carotid sheath. Fig. The pretracheal compartment of Stiles is limited above by the hyoid bone. or space of Burns.37 These spaces of the visceral compartment. http://web. The other is located behind the prevertebral fascia. and is chronic. The posterior lamina is attached to the posterior aspect of the manubrium. The anterior lamina is attached to the anterior surface of the sternum. 1-30) are as follows: Anterior: Pretracheal fascia Posterior: Prevertebral fascia Lateral: Carotid sheath Superior: Hyoid bone and thyroid cartilage Posteroinferior: Posterior mediastinum Anteroinferior: Bifurcation of the trachea. at the level of the 5th thoracic vertebra The contents of the visceral compartment are the larynx. Within this space are the lower ends of the anterior jugular veins and an interconnecting venous arch. One is anterior to it. between the fascia and the posterior lateral wall of the pharynx. 1-32). The lower part of the visceral compartment is subdivided into an anterior pretracheal space and a posterior retrovisceral (retroesophageal) space. Neck Part of a diagrammatic semifrontal section.5/24/2014 Print: Chapter 1. 1-28A&B. 71 percent spread through the retrovisceral space. Some lymphatic tissue and fatty tissue are often present here as well. parathyroid glands.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. and part of the esophagus. Spaces below the Hyoid Bone The following are the spaces below the hyoid bone (Fig. These spaces are separated by lateral attachments of the esophagus to the prevertebral fascia. trachea. and enters below into the anterior mediastinum. 21 percent through the carotid sheath. It can be approached surgically by any kind of incision medial to the sternocleidomastoid and carotid sheath. thyroid. are the chief pathways of infection. the danger space of Grodinsky and Holyoke 37 (see "Prevertebral Layer" under "Deep Fascia" in this chapter) The suprasternal space. Pearse40 stated that in neck infections that spread to the mediastinum.htm 32/125 . 1-30): Visceral compartment (of Stiles) Carotid sheath (see "Carotid Sheath" under "Deep Fascia" in this chapter) Space between the prevertebral and alar fasciae. slanted somewhat anteriorly from behind the ramus of the mandible. VISCERAL COMPARTMENT The boundaries of the visceral compartment of the neck (the space of Stiles) (Fig. to show the relations of the superficial layer of fascia to the parotid gland.uni-plovdiv. The spaces are confluent above. and 8 percent through the pretracheal space. Surgical Applications of the Cervical Fasciae and Spaces Two abscesses are related to the prevertebral fascia. SUPRASTERNAL SPACE The suprasternal space (space of Burns) is formed by a splitting of the superficial investing layer of the deep cervical fascia. This is an acute retropharyngeal abscess (Fig.

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Collections of fluid deep to the prevertebral fascia can track distally down the upper extremity to the level of the elbow by transit within the axillary sheath.

Fig. 1-32.

Chronic and acute retropharyngeal abscesses.

Vascular Supply of the Neck
Despite the fact that we will present the vascular supply of each organ in the neck, at the present time the overall vascular supply will be presented in
summary fashion. The topographic anatomy presented here is based on Montgomery.41

Arteries
COMMON CAROTID ARTERIES
The neck is supplied by the common carotid arteries. The right common carotid arises from the bifurcation of the brachiocephalic trunk and the left common
carotid from the aortic arch (Figs. 1-33, 1-34).
Fig. 1-33.

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Diagrammatic representation of both common carotid arteries (posterior view). (Modified from Montgomery RL. Head and Neck Anatomy: With Clinical Correlations.
New York: McGraw-Hill, 1981; with permission.)

Fig. 1-34.

Common carotid artery and internal and external carotid arteries. (Modified from Montgomery RL. Head and Neck Anatomy: With Clinical Correlations. New York:
McGraw-Hill, 1981; with permission.)

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Print: Chapter 1. Neck

General Topography
The common carotid artery can be divided arbitrarily into three parts: inferior, middle and superior. The inferior part is behind the sternoclavicular joint on the
right, and is intrathoracic on the left. The middle section is located in the neck. The superior part bifurcates to the internal and external carotid arteries.
In most cases the common carotid artery has no branches in the neck. However, we have often seen the superior thyroid artery arise from the superior part
of the common carotid artery just below and close to the bifurcation, which is the most common location of the carotid body (Fig. 1-35).
Fig. 1-35.

Schema of the embryology, anatomy, and physiology of the carotid body and carotid sinus, and the pathology of the carotid body. (Modified from Singhabhandhu B,
Gray SW, Bryant MF, Skandalakis JE. Carotid body tumors. Am Surg 1973;39:501-508; with permission.)

Remember
The common carotid arteries are enveloped within the carotid sheath together with the internal jugular vein and the vagus nerve.
At its cranial end, the internal jugular vein is ventrolateral to the common carotid artery. More inferiorly, it becomes dorsolateral to the artery.
The vagus nerve is between these two vessels in a posteromedial position.

The vertebral artery normally arises from the first part of the subclavian artery, thereafter passing into the transverse foramen of the 6th cervical vertebra. In about
4% of cases, the left vertebral artery arises directly from the aortic arch. In approximately 6% of cases, the vertebral artery may enter the 7th or 5th transverse
foramen; rarely it enters at even higher levels. The surgical significance of high entry is that in such cases the inferior thyroid artery may pass deep to the aberrant
vertebral artery. This results in a potential for fatal hemorrhage or injury to other structures if the artery is torn while attempting to mobilize the inferior thyroid
artery.
Johnson et al.42 reported that early recurrent stenosis of the carotid artery occurred less frequently after endarterectomy using polytetrafluoroethylene (PTFE)
patch angioplasty than with primary closure or in dacron patch angioplasty.

Relations
Topographically, the origin of the right common carotid is located behind the right sternoclavicular joint. The origin of the left common carotid is

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6½ cm. facial. above the omohyoid muscle. the platysma muscle and the superficial investing layer of the deep cervical fascia cover the artery. In the region of the muscular triangle. terminating at the level of the 4th cervical vertebra and at the superior level of the thyroid cartilage. the platysma muscle and the superficial investing layer of the deep cervical fascia should be incised.5/24/2014 Print: Chapter 1. a hypertrophic thyroid gland will cover the common carotid artery. 1-36. and 7th cervical vertebrae Vertebral artery and vein Medial to the common carotid are the following anatomic entities: Lower part of the pharynx Thyroid cartilage Cricoid cartilage Lateral aspect of the thyroid lobe Branches of the inferior thyroid artery Recurrent laryngeal nerve Esophagus Trachea At the right sternoclavicular joint.41 collateral circulation of the common carotid artery (Fig. the carotid is crossed by the superior thyroid artery and vein and its sternocleidomastoid branch. Variations of the great arteries of the carotid triangle were studied by Lucev et al. The surface anatomy of the common carotid can be outlined by a line drawn from the sternoclavicular joint to the neck of the mandible posteriorly. there. The posterior relations are as follows: Retropharyngeal space Prevertebral fascia Cervical sympathetic nerves and ganglia Longus coli muscle Longus capitis muscle Anterior tubercles of the transverse processes of the 4th. 6th. and temporal with corresponding arteries of the opposite side Anastomosis of the ophthalmic with the angular Fig.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. lingual. as it enters the root of the neck. At that level the two common carotid arteries are 2½ 3½ cm apart. the common carotid is medial to the internal jugular vein. the pathway of the common carotids is different. the middle thyroid vein crosses anterior to the artery. and the infrahyoid muscles and their fasciae should also be incised.43 in an excellent paper that we recommend to the interested student. both carotid arteries have a length of 8-12 cm. Neck intrathoracic. At the carotid triangle the artery has anterior. 5th. In each triangle. it passes posterior to the left sternoclavicular joint. From that point. occipital. 1-36) is carried on chiefly by: Anastomosis of the internal carotid of one side with the internal carotid of the opposite side and with both vertebral arteries through the cerebral arterial circle Anastomosis of the inferior thyroid with the superior thyroid Anastomosis of the deep cervical branch of the costocervical trunk with the descending branch of the occipital Anastomosis of the superior thyroid. The larynx separates them from one another at 5½ . The left carotid is behind the internal jugular vein. the sternocleidomastoid muscle should be retracted medially. The thoracic duct is located dorsal to the artery on the left.uni-plovdiv. separated by the trachea. posterior and medial relations of importance.htm 36/125 . Collateral Circulation According to Montgomery. There they bifurcate to the external and internal carotid arteries. http://web. To explore the artery in this area. The right recurrent laryngeal nerve crosses the dorsal side of the first part of the right common carotid artery. Anteriorly.

Fig.htm 37/125 . 1-37) is located within the carotid triangle. the chief longitudinal anastomoses. Neck Some of the collateral channels available after ligation of the common carotid artery.uni-plovdiv.5/24/2014 Print: Chapter 1. It is crossed laterally by the hypoglossal nerve. since its supply is limited to intracranial structures. 1-37. on the left. http://web. On the right side of the body are shown the chief communications between the two sides. INTERNAL CAROTID ARTERY The internal carotid artery (Fig. The internal carotid does not give origin to any branches in the neck. under and deep to the stylohyoid muscle and the posterior belly of the digastric muscle.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.

EXTERNAL CAROTID ARTERY General Topography The external carotid artery begins at the bifurcation of the common carotid artery at C4.49 the external carotid artery also delivers blood to the internal carotid (by virtue of the anastomoses of the two). They also reported that 30% of patients who had tumors of the carotid body died as a result of ligation of the internal carotid. Head and Neck Anatomy: With Clinical Correlations.uni-plovdiv. and facial arteries arise from the ventral aspect near the origin of the external carotid.48 Several nerves of the neck are related to the internal carotid artery. occipital and posterior auricular branches arise from the dorsal side of the external carotid. occipital. The internal carotid may be absent rarely. facial. it is sufficient in only 50% of the cases. The external carotid is located superficially and somewhat anterior and medial to the internal carotid artery. and posterior auricular arteries. The ligation can be done above or below the origin of the superior thyroid artery if necessary.51 there was a death rate of 4% following ligation of the internal carotid for intracranial aneurysms. thus diverting even more blood flow from the brain. even if there is no vascular disease. Ligation of the common carotid artery has been said to reduce the blood flow of the internal carotid artery and.36 According to Roberts et al. superior thyroid. Ligation of the internal carotid artery should be absolutely avoided (Fig.7% in a study of internal carotid ligations in 51 cases for reasons other than intracranial aneurysms. Neck Internal and external carotid arteries.) An aberrant internal carotid artery was reported by Cole and May44 as a vascular abnormality of the middle ear. But.46 reported six cases of segmental agenesis of the internal carotid artery. Relations The hypoglossal nerve passes lateral and anterior to the external carotid artery just above the level of the hyoid bone. lingual.5 cm below the zygomatic arch) where it bifurcates to form the maxillary and superficial temporal arteries. Intervening between the internal and external carotid arteries are several anatomic entities: stylopharyngeus muscle styloglossus muscle styloid process glossopharyngeal nerve pharyngeal branches of the vagus nerve The anatomy of the branches of the external carotid artery will be discussed with related organs. with permission.50. The superior thyroid.53 reported 133 cases of aneurysm arising from the internal carotid artery. the supply to the brain by approximately 50%.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.47 recommended Doppler screening examinations to detect asymptomatic carotid stenoses. SURGICAL APPLICATIONS OF ARTERIAL ANATOMY Occasionally the external carotid artery may be absent on one or both sides. According to Dandy. The common carotid may bifurcate high at the level of the hyoid bone. 1-38). New York: Mc Graw-Hill. This occurs because flow tends to be from the internal carotid to the external carotid (the opposite of that anticipated). They used internal carotid occlusion in 131 cases and common carotid occlusion in 2. and stated that Hunterian proximal arterial occlusion can be done with safety. or lower at the level of the cricoid cartilage. Ligation of the external carotid artery can be done with impunity if the internal carotid artery is not injured (Fig. (Modified from Montgomery RL. Carsten et al. the ascending pharyngeal. http://web. ascending pharyngeal. according to Hollinshead 36 (see Fig. therefore. These findings suggest a possible need for modifying surgical technique during endarterectomy. Papon et al. The 8 variable branch arteries of the external carotid are: maxillary. superficial temporal. unilateral ligation of the artery should never be done unless it is absolutely necessary. lingual. Pemberton and Livermore 52 reported a death rate of 15.5/24/2014 Print: Chapter 1. Drake et al.htm 38/125 . It continues upward to a point posterior to the neck of the mandible (approximately 1. 1-36). Despite abundant collateral circulation of the common carotid artery. It is important to be aware of potential injury to cranial nerves XII and X. 1981. 1-38). Meder et al.45 discussed the existence of anastomoses between the internal carotid and vertebral arteries (or artery) in the neck. especially during carotid surgery. The branches of the missing vessels arise from the external or common carotid on the other side. These authors were able to collect 45 cases..

Neck Fig.htm 39/125 . and selective observation. Kuehne et al. Ballotta et al. In the discussion section of the article by Kuehne et al.56 the only therapy offering any potential cure or palliation in advanced head and neck cancer with involvement of the carotid artery is resection of the carotid artery. 2.54 As reported by Okamoto. Hemodynamically stable patients with suspected internal carotid artery (ICA) injuries undergo a diagnostic angiography.uni-plovdiv. The algorithm is as follows: 1.54 found that the neurologic outcome after internal carotid artery injury is enhanced by an algorithm based on the liberal use of angiography. Marien and Thompson57 report a case of an anomalous occipital artery originating from the cervical internal carotid artery and not from the posterior wall of the external carotid artery..55 or cerebrovascular morbidity such as cerebral edema and herniation. the internal http://web. Until it reaches the level of the superior border of the thyroid cartilage. Guterman et al. and completion angiography are employed.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. X. Neurologically intact patients with ICA occlusion are treated by anticoagulation and mild pharmacological hypertension. 1-39) is the principal vein of the head and neck.5/24/2014 Print: Chapter 1. The authors responded that they had been able to repair the majority of injuries using standard techniques.59 reported that carotid endarterectomy for revascularization of the cervical carotid bifurcation provides a good alternative to open surgery for patients who are considered at risk for excessive morbidity and mortality. and XI. through the jugular foramen. Minimal nonocclusive injuries are managed nonoperatively and followed up by serial angiography or duplex ultrasonography. 3. The patient with injury of the internal carotid artery may develop hemorrhagic infarction in the reperfused ischemic brain. along with cervical nerves IX. Ligation guidelines. These authors also do not advocate ligation of the internal carotid artery.58 stated that cranial and cervical nerve injury after carotid endarterectomy is a common major or minor complication. Reconstruct surgically accessible injuries regardless of neurologic status. The vein exits the skull. a predefined surgical approach. Heparinization. with two exceptions: a. Veins INTERNAL JUGULAR VEIN The internal jugular vein (Fig. shunting.54 the ability to repair the internal carotid artery was questioned because of the relative inaccessibility of two-thirds of its length. 1-38. it is the downward continuation of the sigmoid sinus. b.

Later.uni-plovdiv. Erb's point is where the external jugular crosses the posterior border of the sternocleidomastoid. through the jugular foramen. The great auricular nerve and the transverse cutaneous nerve are of particular importance because of their sensory supply to the lower part of the ear and the lower part of the face in the region of the angle of the mandible. Fig. It usually ends by piercing the superficial investing layer of deep fascia and joining the subclavian vein. This is also the site of the exit of cranial nerve XI. Neck along with cervical nerves IX. here. including transverse cervical and suprascapular veins. 1-39. Until it reaches the level of the superior border of the thyroid cartilage.) EXTERNAL JUGULAR VEIN The external jugular vein passes obliquely and superficial to the sternocleidomastoid muscle deep to the platysma. it is located anterior to the artery. the external jugular vein communicates with the internal jugular and receives a number of tributaries in the neck. close to its termination. and XI.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. (Modified from Montgomery RL. with permission. Internal jugular vein. at the junction of the posterior division of the retromandibular vein with the posterior auricular vein. X. Head and Neck Anatomy: With Clinical Correlations. the vein is very closely related to several of the cervical cutaneous nerves. Lymphatic Structures of the Neck http://web. The veins that empty into the internal jugular vein will be described with the related organs. it takes a position along the lateral side of the common carotid artery within the carotid sheath. the internal jugular vein lies to the external side of the internal carotid artery. although it can also terminate in the internal jugular. In its course. 1981. New York: McGraw-Hill. It is located under the sternocleidomastoid muscle. Finally. The external jugular vein begins near the angle of the mandible. Remember The external jugular vein may be ligated with impunity if the internal jugular vein is intact.5/24/2014 Print: Chapter 1.htm 40/125 .

5/24/2014 Print: Chapter 1. Carlson and J. Lymph Nodes and the Lymphatic Drainage of the Head and Neck Lymphatics Location From To Submental nodes Submental triangle Skin of chin.htm 41/125 . oral cavity. the lymph nodes of the neck are divided into 5 groups. 1996). Fig. 1-40. the "chains" of nodes are shown in Fig. This may equal a mass half the weight of the liver. or levels. jugular chain. Gray SW. Bailey & Love's60 reported that there are about 800 lymph nodes in the human body. medial surface of pinna. except forehead and part of lower lip Intermediate jugular nodes. 1983. http://web. Table 1-2. "There are many lymph nodes in the first echelon drainage of the oral cavity and oropharynx that are never surgically removed so I feel that the total number of lymph nodes could be approximately 150 to 300. with 60-70 in the region of the head and neck. Anatomical Complications in General Surgery. and mastoid area Supraclavicular and deep cervical nodes All other nodes of neck Lymphatic trunks to left and right thoracic ducts Superior horizontal chain: Occipital nodes Vertical chain: Posterior cervical (posterior triangle) nodes Superficial Along exterior jugular vein Deep Along spinal accessory nerve Intermediate (jugular) nodes Juguloparotid (subparotid) Angle of mandible.W. New York: McGraw-Hill. occipital. near parotid nodes nodes Jugulodigastric (subdigastric) nodes Junction of common facial and internal jugular veins Jugulocarotid (bifurcation) Bifurcation of common carotid artery Palatine tonsils Tongue. 300 of which are in the neck.E.64 From a surgical standpoint.63. tip of tongue Submandibular nodes or jugular chain Submandibular nodes Submandibular triangle Submental nodes. Skandalakis. with permission." Drinker and Yoffey62 wrote that all the lymphoid tissue in the human body (including the lymphocytes in bone marrow) probably corresponds to nearly 1% of the total body weight. floor of mouth. vertical chain Jugular or subclavian trunks to right lymphatic duct and thoracic duct Anterior (visceral) nodes Prelaryngeal (Delphian) nodes Pretracheal nodes Inferior horizontal chain: Supraclavicular and scalene Subclavian triangle nodes Source: Skandalakis JE. esophagus Deep cervical and mediastinal nodes Axilla. April 22. Neck Lymphatic Structures of the Neck NUMBER OF LYMPH NODES There is a significant range in the number of lymph nodes believed to be in the neck. We consider the system of Healey65 to be the best and the easiest to remember. except tip nodes close to carotid body Juguloomohyoid (omohyoid) nodes Crossing of omohyoid and internal jugular vein Tip of tongue Parapharyngeal nodes Lateral and posterior wall of pharynx Deep face and esophagus Intermediate nodes Paralaryngeal nodes Lateral wall of larynx Larynx and thyroid gland Deep cervical nodes Paratracheal nodes Lateral wall of trachea Thyroid gland. pharynx Deep cervical nodes Anterior wall of trachea below isthmus of thyroid gland Thyroid gland. side of scalp Deep cervical nodes Postauricular (mastoid) nodes Mastoid process Temporal scalp. Rowe JS Jr. The groups composing these chains are listed in Table 1-2. In contrast.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. trachea. however. deep posterior cervical nodes Preauricular (parotid) nodes In front of tragus Lateral surface of pinna. trachea. Some of the nodes of the intermediate vertical chain are shown in Fig. LEVELS OF THE NODES The anatomy and pathology of cervical and retropharyngeal lymph nodes has been evaluated by computed tomography by Mancuso et al. Carlson stated (personal communication between G. lip. There is no widespread agreement on the nomenclature of lymph nodes and their division into groups. esophagus Deep cervical and mediastinal nodes Cricothyroid ligament Thyroid gland. external auditory meatus Deep cervical nodes Between mastoid process and external occipital protuberance Back of scalp Deep cervical nodes Subparotid nodes. Gray's Anatomy61 reported that the adult body contains only 400-450 lymph nodes. face. 1-41. thorax.uni-plovdiv. 1-40.

Anatomical Complications in General Surgery. Neck The lymph nodes of the neck from Healey's classification. The juguloomohyoid and deep lower jugular lymph nodes are located within this space. Level III (Midjugular Chain) This is a near-triangle formed (below) by the anterior belly of the omohyoid muscle. Superior horizontal chain. Arbitrarily. IH. Anterior vertical chain. 1983. 1983. Level IV (Lower Jugular Chain) The boundaries of Level IV consist of the posterior or lateral border of the lower third of the sternocleidomastoid. IV. and inferiorly of the clavicle. Posterior vertical chain. SH. 1-41.e. with permission. Some drainage to lymph nodes of the intermediate vertical (jugular) chain. The jugulodigastric (subdigastric) node also belongs to this level.htm 42/125 . laterally (posteriorly) by the posterior border of the middle one-third of the sternocleidomastoid muscle.uni-plovdiv. Level V (Posterior Cervical Triangle) This is the posterior triangle of the neck. Rowe JS Jr. which includes the posterior cervical lymph nodes in toto (spinal accessory nodes. (Modified from Skandalakis JE. Inferior horizontal chain.66 reported a small incidence of supraspinal lymph node metastasis in patients with squamous cell carcinoma of the oral cavity and oropharynx http://web. Gray SW.) Level I (Submental and Submandibular Nodes) Level I consists of all lymph nodes within the submental and submandibular triangles. The boundary extends above to the occipital area and below to a line corresponding to the pathway of the great auricular nerve.5/24/2014 Print: Chapter 1. where it crosses the upper part of the sternocleidomastoid obliquely.) Fig.. AV. superiorly of the omohyoid muscle. Rowe JS Jr. scalene nodes). i. Anatomical Complications in General Surgery. with permission. New York: McGraw-Hill. (Modified from Skandalakis JE. Gray SW. between the anterior midline and the anterior border of the posterior belly of the digastric muscle. New York: McGraw-Hill.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Level II (Upper Jugular Chain) This level includes all deep jugular lymph nodes in the upper one-third of the neck. and medially by the hyoid bone. Kraus et al. inferior horizontal chain. that area is bounded by the upper one-third of the posterior border of the sternocleidomastoid muscle and the medial border of the posterior belly of the digastric. PV. Intermediate vertical chain.

SPECIAL LYMPH NODES Virchow's node. 1-42 shows the lymph nodes into which they drain. 1983. (Modified from Skandalakis JE. Tonsils The opening between the nasal and oral cavities and the pharynx is guarded by a group of lymphoid structures collectively referred to as the ring of Waldeyer (Fig. The lingual tonsils are at the inferior aspect of the ring.2 percent). lymphatic vessels. Fig. 1-42. even the most perfunctory physical examination will reveal the swelling. is the pharyngeal tonsil (adenoids). In most cases. it is usually presumptive evidence of malignant neoplasm below the diaphragm. 3. The Delphian node is found just above the thyroid isthmus. The neck also contains a number of subepithelial lymphoid structures. also called the signal node. Skandalakis et al. is located just above the middle third of the left clavicle. between the pharyngeal and palatine tonsils.123 were of nonthyroid origin (53.) On the roof of the nasopharynx. The lymphoid structures of the tonsillar ring of Waldeyer surrounding the pharynx. Anatomical Complications in General Surgery.67 examined reports of 7. Of these.5/24/2014 Print: Chapter 1. the lateral band. The rules offer a well-marked pathway to diagnosis of nonthyroid neck masses. MASSES IN THE NECK The human neck is designed such that the swelling of a normal structure or the presence of an abnormal one is readily apparent.uni-plovdiv.625 were of thyroid origin (46. Neoplasms and infections can affect any of the 60-70 lymph nodes or the more than a dozen fascial spaces in the neck. Neck with negative lymph nodes. These tonsillar organs differ from lymph nodes in that they provide origin to. New York: McGraw-Hill. Rowe JS Jr. but do not receive. Laterally. 1-42).bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. the palatine tonsils guard the entrance to the pharynx. on the sides of the base of the tongue. Gray SW. Persistent embryonic structures may occupy spaces no longer available to them. There may be a band of superficial lymph nodules.256 surgical admissions from 1954 to 1972. Fig. the tonsils.htm 43/125 .748 neck masses found in 232. at the superior aspect of the ring of Waldeyer. When sufficiently enlarged and firm enough to be palpable. with permission. two rules became apparent.8 percent) and 4. Rule of 80 The Rule of 80 for Neck Masses is as follows. 80 percent of: nonthyroid masses are neoplastic neoplastic masses are in males neoplastic masses are malignant malignant masses are metastatic http://web. With a little rounding of the figures in the above study. The structures of the neck are packed so tightly that nearly every lesion expresses itself as a visible or palpable bulge.

Injury to the duct in supraclavicular lymph node dissections results in copious lymphorrhea. and descends slightly as it passes behind the common carotid artery to enter the left subclavian vein (Fig. but there are none along its upward course. Lymph nodes may be present at the caudal end. Johns and Mills72 elaborated on the relationship of vigorous stem cell populations. the authors think that both rules remain useful and worth remembering.74 It ascends on the right side of the midline on the anterior surface of the bodies of the thoracic vertebrae. and loss of proteins and electrolytes. and reported that surgery. depletion of body fluids. New York: McGraw-Hill. 1-43) at its junction with the left internal jugular vein. from the junction of the right and left lumbar lymphatic trunks and the intestinal lymph trunk. We quote from Johns:71 .73 reported that the human colony-forming assay test contributed to the understanding of the cellular origins of salivary gland lesions and the chemosensitivities of salivary gland carcinomas.70 studied patients with metastatic squamous carcinoma of the neck and occult primary lesion. as well as from much of the left side of the thorax. Fig.htm 44/125 . The duct may have multiple entrances to the vein. since most patients will have several other groups of lymph nodes involved.68 and Feldman et al. Lyles et al. and the development of recurrences and metastases in squamous cell carcinomas of the head and neck. Trunks are variable and may enter the veins with the thoracic duct or separately.75 advocate the treatment of chronic thoracic duct fistula using a sternocleidomastoid muscle flap. The thoracic duct and main left lymphatic trunks. The duct passes behind the great vessels at the level of the 7th cervical vertebra. . with permission. as measured by cloning efficiency. . It crosses the midline between the 7th and 5th thoracic vertebrae to lie on the left side. or both can cure about 50% of patients with an unknown primary tumor.69 found fine-needle aspiration reliable and safe in the management of squamous cell carcinoma of the head and neck.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. and one or more of the contributing lymphatic trunks may enter the subclavian or jugular vein independently. 1983. It can be ligated with impunity. The best diagnosis of primary or metastatic head and neck masses is a complete clinical evaluation and biopsy or biopsies. Clonal assay of head and neck tumors was the topic of several papers from the early 1980's. The Rule of 80 and Rule of 7 were based on hospitalized patients with cervical lymphadenopathy.Ultrastructural studies are particularly helpful in delineating the characteristics of tumor stem cells and understanding the histogenesis of neoplasms.uni-plovdiv. Lee et al.5/24/2014 Print: Chapter 1. .) The thoracic duct collects lymph from the entire body below the diaphragm. Low cloning efficiency (<0. irradiation. (Modified from Skandalakis JE.005%) was associated with early recurrence of cancer or death from the disease. to the left of the esophagus. In spite of the impossibility of such a statistical analysis being duplicated today (most patients with cervical lymphadenopathy are treated as outpatients). Rowe JS Jr..The clonogenic soft agar assay for head and neck tumor cells is a useful tool for studying their biology and growth characteristics. Neck metastatic masses are from primary sites above the clavicle Rule of 7 The Rule of 7 provides a probable diagnosis of the neck mass based on the average duration of the patient's symptoms.005%) was associated with good probability of survival.. crossing ventral to the vertebral artery. It is from 38 to 45 cm long. Wechselberger et al. Anatomical Complications in General Surgery. RIGHT LYMPHATIC DUCT http://web. Johns et al. They advised thorough evaluation prior to surgery to locate the primary tumors. whereas high cloning efficiency (0. . such as axillary nodes and inguinal nodes. THORACIC DUCT The thoracic duct originates from the cisterna chyli and terminates in the left subclavian vein. Ligation is the answer. if the cisterna is absent (about 50 percent of cases). The duct arises at about the level of the 2nd lumbar vertebra from the cisterna chyli or. Gray SW. 1-43. 7 days: inflammation 7 months: neoplasm 7 years: congenital defect AIDS (Acquired Immune Deficiency Syndrome) may have changed these numbers.

neck.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. 1-45). Neck The right lymphatic duct —a variable structure about 1 cm long— is formed by the right jugular. rather than on details of the action of this system. If these trunks enter the veins separately. Each gives grey rami communicantes to the cervical nerves. Fig. It drains the right side of the head. we think it is appropriate here to present a brief summary of the nerves in general. and a plexus to an artery. X. with the sympathetic trunk of the thorax. middle. and inferior) (Fig. intracranial area. and several other nerves are covered in the discussion of anatomic complications of surgery for metastatic disease of the neck in the section on radical neck dissection. there is still much we do not know. IX. Even though knowledge of the system has increased. When present. 1983. in the thyroid section of this chapter and in the stomach chapter (vagus nerve). most of the right side of the thorax. the right lymphatic duct enters the superior surface of the right subclavian vein at its junction with the right internal jugular vein. XII) are covered in detail in several parts of this book. Perhaps Sir William Turner was right when he stated. XI. Anatomical Complications in General Surgery.uni-plovdiv. X. It is continuous. there may be no right lymphatic duct. but originating in the neck. IX. 1-45. with permission. It extends above into the skull as a plexus surrounding the internal carotid artery. "The sympathetic begins nowhere.htm 45/125 . such as the section on parotid glands in this chapter (facial nerve). New York: McGraw-Hill. and mediastinal lymphatic trunks (Fig. 1-44). http://web.5/24/2014 RIGHT LYMPHATIC DUCT Print: Chapter 1."76 Cervical Sympathetic Nerves The sympathetic trunk of the neck is in the prevertebral fascia between the carotid sheath in front and the longus colli and longus capitis muscles behind. traveling all over the neck but with a definite anatomic destiny to supply the vessels of the head. The cervical sympathetic chain is formed by three ganglia (superior. Rowe JS Jr. a cardiac nerve. The emphasis here will be on the topography of the ganglia of the sympathetic chain and their branches. transverse cervical.) Nerves of the Neck Although the innervation of some of the anatomic entities of the neck is described in detail in this chapter. (Modified from Skandalakis JE. right upper limb. and upper extremities. there is no right lymphatic duct. are as follows: 5 cranial nerves (VII. representing the terminal part of the right thoracic duct. XI. It is the remnant of the original embryonic system of bilaterally symmetric right and left thoracic ducts. The nerves of the neck form a peculiar pathway from above downward. and the lower two-thirds of the left lung. XII) cervical sympathetic nerves cervical plexus (superficial and deep) brachial plexus Five Cranial Nerves The cranial nerves (VII. Fig. The right lymphatic duct is formed by the junction of several lymphatic trunks. 1-44. The nerves that are responsible for the innervation of some anatomic entities in the neck or other territories. internal mammary. downward. Gray SW. If they enter the veins separately.

McGregor and DuPlessis76 stated that the plexus around the internal carotid artery communicates with the vagus. which is the smallest of the three (about 3 mm in diameter). It is the largest of the three ganglia and is located just behind the sheath of the internal carotid artery. forms a plexus around the external carotid artery. Anson and McVay77 stated that the ganglion should not be excised unless its sympathetic communicating strand leads to the middle cervical ganglion. (Modified from Decker GAG. and between the transverse process of the 7th cervical vertebra and the neck of the 1st rib. The fascia covers the longus capitis muscle. The 1st thoracic and inferior sympathetic ganglia are often united to form the stellate ganglion. and finally gives origin to the superior cardiac nerve and the carotid nerve.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. gives a branch to the pharyngeal plexus. and the middle cardiac nerve. Du Plessis DJ (eds). glossopharyngeal.uni-plovdiv. flat. The inferior cervical ganglion (cervicothoracic or stellate) is situated behind the vertebral artery.) The uppermost ganglion. the rest of the thoracic sympathetic chain can be found inferior to it beneath subclavian vessels and in the upper mediastinum. is a reddish. It is interconnected to the inferior cervical ganglion. Lee McGregor's Synopsis of Surgical Anatomy (12th ed). this prevents mistaking it for the nodose ganglion of the vagus nerve. the stellate ganglion can usually be found posterior to it. The superior sympathetic ganglion of the neck gives grey rami communicantes to the first cervical nerves (1 to 4). and it gives origin to the inferior cardiac nerve. is located at the level of the 6th cervical vertebra and the cricoid cartilage. Bristol. it surrounds as a plexus the subclavian artery and its branches. Another landmark is the vertebral artery.27 discussed the topographic anatomy of the stellate ganglion: Ansae or small rootlets enter and leave T1 and can lead the surgeon to the stellate ganglion and then the caudal portion of the thoracic sympathetic chain. The ganglion rests on the prevertebral fascia in the area of the transverse process of the 2nd and 3rd cervical vertebrae. It is larger than the middle ganglion but smaller than the superior cervical ganglion. http://web. Kline et al. By elevation of the proximal portion of the vertebral artery. and hypoglossal nerves. a plexus around the inferior thyroid artery. The middle cervical ganglion gives grey rami communicantes to the 5th and 6th cervical nerves. SURGICAL APPLICATIONS Remember The nodose ganglion (ganglion inferius) of the vagus nerve is close to the superior cervical ganglion. which can be found originating from the proximal portion of the subclavian and running upward and medially toward the tranverse processes of C6. We agree with McGregor and DuPlessis that it is always present. England: John Wright. The inferior thyroid artery is an excellent landmark for the topography of this ganglion which is located anterior or posterior to the artery.htm 46/125 . and medial to the descending branch of the costocervical branch of the subclavian artery. Topographically the middle cervical ganglion. It gives grey rami communicantes to C7-C8 cervical nerves.5/24/2014 Print: Chapter 1. 1986. Neck The cervical sympathetic trunk. with permission. ellipsoidal structure. the superior cervical ganglion.

The upper pathway of the phrenic nerve is a landmark for the location of the 5th and 6th cervical nerves during neck exploration. Fig. It is located between the root of the first thoracic and the second thoracic intercostal nerves. carefully dissect the inferior part of the stellate ganglion. lesser occipital (C2) great auricular (C2.) The superficial group (Fig. C3.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. 2nd. The branches of the cervical plexus consist of two groups: superficial and deep. Philadelphia: BC Decker.htm 47/125 . The physiologic action of this ramus may relate to the sympathetic chain. 1-46) is formed by the anterior divisions of the spinal nerves C1-C4 and is located between the middle scalenus muscle and the levator scapula. When the stellate ganglion (ganglion cervicothoracicum) is removed it produces Horner's syndrome (see "Anatomic Complications of Thyroidectomy"). (Modified from Healey JE Jr. It is covered by the SCM muscle. The nerve of Kuntz is a highly variable anatomic entity within the upper thorax. and C4. at which point the superficial plexus exits. C3) http://web. 3rd. Neck excised unless its sympathetic communicating strand leads to the middle cervical ganglion. 1-47) is formed by the anterior primary divisions of cervical nerves C2. or transpleural thoracoscopic approach may be used for cervicodorsal sympathectomy. The physiologic destiny of this group is sensory. Low anterior cervical. 1990.77 Removal of the stellate ganglion as well as the 1st.uni-plovdiv. 1-46. Occasionally. with permission. To avoid Horner's syndrome. The following nerves belong to the superficial group and all of them will be seen in the vicinity of the middle part of the posterior border of the SCM muscle. and maybe the 4th thoracic ganglia (cervicodorsal sympathectomy) is done occasionally for severe Reynaud's phenomena (vasospastic disease of the upper extremity and severe palmar hyperhidrosis) in the hope that the pain secondary to the vascular spasm will be alleviated. the thorascopist confuses the ligament with the chain. Superficial and deep cervical plexuses.79 Cervical Plexus The cervical plexus (Fig.5/24/2014 Print: Chapter 1.78. transaxillary. The cervical sympathetic chain is located lateral to the anterior spinal ligament. Surgical Anatomy. Hodge J. and will not perform a cervical sympathectomy. this prevents mistaking it for the nodose ganglion of the vagus nerve.

sternohyoid. Neck transverse cervical (C2. Superficial group of the cervical plexus.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. The branches are formed by the anterior divisions of C1-C4 nerves. C3. Hodge J. with permission.htm 48/125 .5/24/2014 Print: Chapter 1. or both) levator scapulae (C3-C4) trapezius (C3-C4 probably proprioceptive. 1-48. 1990. sternothyroid. C4) Fig. 1-48) is motor. (Modified from Healey JE Jr.uni-plovdiv. 1-47. 1-46. innervating the strap muscles of the neck and the skin and diaphragm. and C3) – geniohyoid (C1) – rectus capitis lateralis (C1) – rectus capitis anterior (C1) – longus capitis (C1-C4) – longus colli (C3-C8) – scalenus anterior (C4-C6) – intertransversalis (C1-C8) sternomastoid (C2. with motor supply from XI) scalenus medius (C3-C7) Fig. The deep group consists of the following nerves: phrenic (C3-C5) muscular branches to strap muscles: omohyoid. thyrohyoid by way of the ansa cervicalis (C1. Surgical Anatomy. C2. http://web.) The deep group (Figs. C3) supraclavicular (C3. Philadelphia: BC Decker.

In addition.htm 49/125 .) Brachial Plexus The brachial plexus is formed by the anterior divisions of the four lower cervical nerves (C5-C8) with participation of the one upper thoracic nerve (T1) (Fig. 1-49. with permission.uni-plovdiv.5/24/2014 Print: Chapter 1. The roots and trunks are located in the neck and are related to the subclavian artery. Fig. Hodge J. trunks. communications from C4 and T2 may also be present. http://web. Surgical Anatomy. it rests on the middle scalene muscle. sternocleidomastoid muscle.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. It is a nerve plexus formed. and terminal nerve branches. Neck Deep group of the cervical plexus. Philadelphia: BC Decker. The brachial plexus emerges from between the anterior and middle scalene muscles. 1990. of roots. divisions. and anterior scalene muscle. cords. 1-49). resting upon the middle scalene. To be more specific the plexus is in the posterior triangle of the neck: it is adjacent to the clavicle. (Modified from Healey JE Jr. subsequently.

SURGICAL APPLICATIONS The brachial plexus in the neck may be palpable in an angle formed between the clavicle and the lower lateral border of the SCM muscle.5/24/2014 Print: Chapter 1. The brachial plexus in the neck is related to the following anatomic entities from superficial to deep: – Anterior skin superficial fascia and platysma branches of supraclavicular nerves deep fascia (roof of posterior triangle) external jugular vein and some of its tributaries omohyoid: posterior belly transverse cervical artery nerve to subclavius muscle third part of subclavian artery in front of the lowest trunk suprascapular artery clavicle – Posterior middle scalene muscle http://web.htm 50/125 . This connective tissue investment becomes the axillary sheath which can be injected with anesthetic in surgical procedures of the upper limb.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Neck Schema of the brachial plexus. As the nerves of the plexus emerge from between the anterior and middle scalene muscles they become ensheathed with the prevertebral fascia covering the muscles.

bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. lateral rotators of the shoulder joint. Schema of the formation of the brachial plexus. and flexors of the elbow joint and supinator muscle. 1-51. The dorsal scapular artery often (50%) passes between the trunks of the plexus. There may be some disturbance of sensibility at the shoulder and at the radial side of the forearm. 1-51) is the junction of several nerves. The suprascapular and subclavian nerves are direct branches from the upper trunk just beyond Erb's point.5/24/2014 Print: Chapter 1. The twigs to the longus and scalene muscles are not shown. Here the upper trunk of the brachial plexus is formed by the union of the 5th and 6th roots of the brachial plexus. Platzer80 categorizes the injuries of the brachial plexus into upper and lower divisions. 1-50. Fig. This very short upper trunk bifurcates forming anterior and posterior divisions. and its branches in the neck. Erb's point (Figs. http://web. Injury to the upper plexus can cause Duchenne-Erb paralysis involving movements of the shoulder joint due to injuries of the roots of C5 and C6 and with secondary involvement of the abductors. Fig. Neck long thoracic nerve – Inferior The lowest trunk lies on the first rib.uni-plovdiv. 1-50. sandwiched between the subclavian artery in front and the middle scalene behind.htm 51/125 . marking it.

In the lower plexus. http://web. or anterior to. the fifth and sixth roots of the brachial plexus going to form C. persistence of any portion is not unusual. nerve to subclavius muscle. 1-52). the large median thyroid anlage. THYROID GLAND EMBRYOGENESIS Normal Development The thyroid gland appears by the end of the third week as an epithelial thickening of the floor of the pharynx at the level of the first pharyngeal pouch. anterior and posterior divisions of the upper trunk. Isolated injuries of the C7 middle trunk are unusual. Meeting are the following nerves: A and B. In some individuals it is not grossly visible. Cranial growth of the tongue. Fig. the supraclavicular nerve of the cervical plexus can be palpated. the hyoid bone. If the upper trunk at Erb's point is stretched or torn during the birth of a child. The site of this origin is the foramen cecum of the adult tongue. 1-52. Erb's point is located just behind the posterior border of the SCM muscle. In a slender person with minimal adipose tissue in the neck. the short muscles of the hand. The triceps reflex disappears. (Modified from Skandalakis JE. The thyroid gland remains connected with the foramen cecum by a minute. suprascapular nerve. G.5/24/2014 Print: Chapter 1. but their presence may be of concern to the surgeon. carries the origin of the thyroid gland far cranial to the gland itself. Erb's paralysis of the upper arm may result. but when they occur. and extension of the elbow and metacarpophalangeal joint may be lost. adduction and medial rotation of the upper limb are weakened. together with elongation of the embryo. Normal vestiges of thyroid gland development. D and E.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. In about 50 percent of the population. F. and loss of sensibilities at the ulnar side of the hand and forearm (Dejerine-Klumpke paralysis).htm 52/125 . trauma to the roots of C8 and T1 may lead to impairment of the long flexors of the fingers. in the vicinity of the transverse process of the 6th cervical vertebra. None are of clinical significance. this duct usually becomes fragmented. By the fifth week of gestation.uni-plovdiv. the duct can be traced distally to the pyramidal lobe of the thyroid gland (Fig. the upper trunk of the brachial plexus. solid thyroglossal duct that passes through. approximately 2-3 cm above the clavicle. may be a diverticulum or a solid bud. Neck The dotted circle is Erb's point. This.

Thymic 2. Intralaryngeal 14. LiVolsi84 stated that lingual thyroid (Fig. C cells belong to a group of neural-crest derivatives known as APUD (amine precursor uptake and decarboxylation) cells.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Gray SW (eds). The student of thyroid anatomy will find complete coverage in Embryology for Surgeons. Ovarian 5. Pharyngeal pouches remnants 1. From the right lobe 6." Congenital Anomalies It is not within the scope of this book to present detailed anomalies or variations of the thyroid gland. Absent 5. Short 1. Symmetry 1. Tumors of the APUD system are collectively called "apudomas. Ectopic thyroid tissue in fat. but their presence may be of concern to the surgeon. Parathyroid 3. Intralymph node a This classification is based on the thyroid anlage(s). Solid cell rests: C cells 2. (Modified from Skandalakis JE. Neck Normal vestiges of thyroid gland development. muscles G. Colloid formation and uptake of radioactive iodine begin at about the eleventh week. pancreas. Source: Skandalakis JE. with permission. Gallbladder 12. Lymph B. Lingual 3. Long 2. and its cells become dispersed as the C (calcitonin) cells among the thyroid follicles. Nonfusion with median anlage A. absent B. Mediastinal 2. http://web. Fat. at the site of the foramen cecum. 1994. we will mention a few common anomalies and discuss in greater detail the lateral aberrant thyroid. Groin 13. but lies beneath the epithelium of the tongue. Nerves F. Ultimobranchial body 4. New York: McGraw-Hill. Right or Left 3. Anomalies of descent along the thyroid line 1.5/24/2014 Print: Chapter 1. Epithelial structures. thin. if any. Retrotracheal 7. 1-53) results from a failure of the median anlage to descend from the pharynx. with permission.81 and later become part of the thyroid gland. Pyramidal lobe E. are formed from the ventral portions of the fourth and fifth branchial pouches. Anatomical Complications in General Surgery. The anatomy of the abnormal is shown in Table 1-3. involving the anomaly. and adrenal glands belong to the APUD system. becomes lost in the developing thyroid gland. Bilobed partial C. medullary carcinomas. Sella turcica 6. 1983. One lobe absent 3. Unilateral D. muscle cartilage within the thyroid gland H. 2nd Ed. Rowe JS Jr. A Classification of Congenital Anomalies of the Thyroid Glanda Both Median and Lateral Anlages Median Anlage Lateral Anlage Neither Anlage A. the well-known ultimobranchial body (caudal pharyngeal pouch complex). Follicles appear during the second month of gestation and increase through the fourth month. Vessels B. Cardiac 10. Cysts with squamous epithelial lining 1. outside the pathway of descent) 1. Variable shape and weight A. From the left lobe 7. 1-53. From the neural crest these cells migrate to the ultimobranchial body. Preaortic 8. None are of clinical significance. Sublingual 3. Thyroglossal duct B. Lateral to jugular 4. at first an irregular plate. Vein D. Agenesis A. Intraesophageal 15. Pyramidal lobe 4. Pericardial 9. Gray SW. Intratracheal 3. Accessory ectopic (i..e.uni-plovdiv. account for 6 to 8 percent of all thyroid malignancies. Several other endocrine-producing cells in the gut and tracheal walls. Total thyroid agenesis 2. This structure. Baltimore: Williams & Wilkins. Fig. Welbourn82 believed that tumors of these cells. Present evidence suggests that the primary origin of the calcitonin-producing cells of the thyroid gland is the neural crest of the embryo. Artery C. the paired lateral anlages. Lingual Thyroid Occasionally the thyroid gland is not in the normal cervical position. Porta hepatis 11. develops two lateral wings connected by the isthmus. Muscles C. Lateral aberrant thyroid not within the capsule of medially located lymph nodes 2. From the isthmus 8. Isthmus: thick.83 However.) The developing gland.htm 53/125 . Agenesis: Lobdell-DiGeorge syndrome E. Table 1-3. Embryology for Surgeons. Prelaryngeal C.

Gray SW (eds). Hyperdescent into the thorax (primarily retrosternal thyroid) is also possible. An ectopic thyroid may remain at its level of origin in the tongue. Failure to remove the central portion of the hyoid bone resulted in 17 percent recurrence in one series of operations. Drainage or aspiration of these cysts is futile and often results in the formation of a fistula. and indicated that fewer than 150 cases have been reported.88 up to 62 percent contain ectopic thyroid tissue. Occasionally these epithelial fragments hypertrophy. and midportion of the hyoid bone should be removed (Sistrunk procedure). Surgical Pathology of the Thyroid. Read an Editorial Comment Persistent Remnants of the Thyroglossal Duct The foramen cecum of the tongue and the pyramidal lobe of the thyroid gland are normal remnants of the thyroglossal duct.42:621-628. A thyroid gland may be found anywhere along the track from the foramen cecum to the normal site. blood vessel. or its descent may be interrupted at any point along the pathway. usually broken in several places. Neck The embryonic path of descent of the thyroid gland.uni-plovdiv. according to LiVolsi. 1990. Quigley et al. Embryological considerations of thyroid surgery: Developmental anatomy of the thyroid. Frequently. It requires care. (Modified from Gray SW. before the ectopic thyroid is excised. In one series. Embryology for Surgeons. the excised tissue can be implanted into the anterior abdominal wall. Table 1-4. Baltimore: Williams & Wilkins. Recurrence of the cyst is the result of failure to remove the entire duct. All fragments of the duct.) The lingual thyroid gland is usually small but normal and is the only thyroid tissue present. Reported Cases of Thyroglossal Duct-Associated Carcinomaa Histology: Papillary carcinoma 99 Adenocarcinoma 2 Malignant struma 1 Squamous cells carcinoma 7 Total (reported cases) 109 Female/Male 66:42 (1 unknown) Age 6 to 81 years History of neck radiation a 3 Adapted from LiVolsi VA. http://web. Akin JT Jr. Am Surg 1976. it is important to evaluate whether it is the only thyroid tissue in the body.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. If no malignancy is reported from frozen sections. Skandalakis JE. individuals who have ectopic thyroid also have an absence of normal thyroid. Therefore. 2nd Ed. Medullary thyroid cancer has not been reported because there are no C cells in the pyramidal lobe (the parafollicular C cells arise from the lateral thyroid anlage). Table 1-4 shows histologic composition and other characteristics of thyroglossal duct-associated carcinoma in 109 cases. because the gland is well vascularized by the lingual arteries. or organ need be injured in this procedure. Embryology and pathology are in full agreement here. Philadelphia: WB Saunders.htm 54/125 . Source: Skandalakis JE.94 warned against inadvertent removal of a partially descended thyroid gland mistaken for a thyroglossal duct cyst.92 Between the foramen cecum and the pyramidal lobe is a very small epithelial tube. and form cysts. with permission. secrete fluid. which usually becomes infected.93 No nerve.8 percent of all the congenital masses of the neck.90 Walton and Koch91 presented a case of thyroglossal duct cyst with papillary carcinoma. with permission. Primary carcinoma in thyroglossal duct cyst occurs in less than 1 percent of cases. Such "partially descended" glands are rare.86 2 out of 12 lingual thyroids were malignant.85 Total excision of a lingual thyroid is necessary. 1994. Thyroglossal duct cysts account for 62. Radioactive iodine scintigraphy will aid in the diagnosis and will determine the presence of other thyroid tissue in the patient.5/24/2014 Print: Chapter 1.87 Of those. and the recurrent laryngeal nerve. foramen cecum.89. parathyroid.

Monchik and Materazzi96 advised that posterior or aberrant mediastinal thyroid masses may require a thoracic surgical approach.103 with metastasis noted in papillary carcinoma. STRUMA OVARII Struma ovarii. According to estimates of Woodruff et al.uni-plovdiv.101 struma ovarii may exist in 0. was lateral aberrant thyroid tissue. by all appearances. Kumar et al.5/24/2014 Print: Chapter 1. the ovarian thyroid.95 described an accessory lobe of the thyroid gland located inferior to both lateral lobes and the isthmus. the existence of heterotopic thyroid tissue within cervical glands has been reported. Rubenfeld et al. pathologist.97 reported an adolescent with dual ectopic thyroid glands located in the sublingual and subhyoid regions.98 It has three morphologic manifestations. Left side of drawing illustrates possible sites of accessory ectopic thyroid tissue. 1994. Right side of illustration lists other anatomic entities from which tissue may be found within the thyroid.100 reported a patient whose only thyroid tissue.htm 55/125 .98.99 The final morphologic expression of laterally aberrant thyroid tissue must be termed congenital. the seventh such case in the literature. This tissue may be found as a nodule attached by connective tissue to the mother gland. Malignancy is a possible occurrence in as many as 5% of all struma ovarii.104 http://web. with permission. are nevertheless normal. These thyroid tissue "islands. Baltimore: Williams & Wilkins.) Bhatnagar et al.2-1. is an extraordinary thyroid ectopia. Its arterial supply originated from the right inferior thyroid artery and its vein drained via the plexus thyroideus impar.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck." which pull away from the visceral body during development. However. LATERAL ABERRANT THYROID Of special interest —and a vexation to surgeon. Fig. Ovarian thyroid tissue is a fellow traveller with dermoid cysts and teratoma. 1-54. (Modified from Skandalakis JE. tissue located lateral to the jugular vein. Neck Accessory Ectopic Thyroid Tissue Figure 1-54 demonstrates not only the possible sites of ectopic tissue but also tissues of other anatomic entities within the thyroid parenchyma. 5-6% are bilateral and about 5% possess functioning thyroid tissue. that is. Gray SW. Always consider the possibility of metastatic thyroid cancer of lateral aberrant thyroid nodules. Of these. Kempers et al.102 found hyperthyroidism in struma ovarii. Six such cases of normal thyroid gland at 5-Ìm sections were described by Sawicki et al. The second site for lateral thyroid tissue is within lymph nodes or their remnants. and patient— is lateral aberrant thyroid tissue. Embryology for Surgeons (2nd ed). although it is unrelated to the anatomic thyroid gland and is not a true congenital anomaly. We should consider a cervical lymph node containing thyroid follicles to be clinically a metastatic thyroid carcinoma.3% of all ovarian tumors..

Droulias C. the artery parallels the external branch of the superior laryngeal nerve which supplies the cricothyroid muscle and the cricopharyngeus muscle. 1-56. Fig. sternocleidomastoid. Usually there are two branches to the thyroid — the anterior and posterior— but occasionally there may be a third. the so-called lateral branch (Fig. the thyroglossal duct. the superior and inferior thyroid arteries. especially in patients with toxic goiter. One lobe. the thyroid gland has a connective tissue capsule which is continuous with the septa.) SUPERIOR THYROID ARTERY The superior thyroid artery arises from the external carotid artery just above. It may lie higher (lingual thyroid). 1-52). The levator muscle of the thyroid is one or more muscular slips that occasionally connect the hyoid bone with the thyroid gland. The thyroid gland normally extends from the level of the 5th cervical vertebra to the body of the 1st thoracic vertebra. In part of its course. This is the true capsule of the thyroid. There are six branches of the superior thyroid artery (Fig. lateral. These vestigial muscles are inconstant in occurrence. Skandalakis JE. posteriorly it is thin and loose. also called the perithyroid sheath or surgical capsule. (Modified from Tzinas S. inferior pharyngeal constrictor.3 cm in breadth. The lobes have a broad lower portion and a relatively conical apex.htm 56/125 . Each lobe is approximately 5 cm in length. Vascular patterns of the thyroid gland. Harlaftis N.107 One consequence is that hemostasis is a major problem of thyroid surgery.105 The normal thyroid gland weighs about 30 g in the adult —somewhat more in females than in males. The arterial supply to the thyroid gland. is not removed with the gland during thyroidectomy. The isthmus is absent in about 10 percent of thyroid glands. Neck SURGICAL ANATOMY General Topography The thyroid gland consists typically of two lobes. but rarely lower. and the pyramidal lobe is absent in about 50 percent (see Fig. The inferior parathyroids may be between the true and false capsules. location. a connecting isthmus. 1-55). and an ascending pyramidal lobe. There is a thickening of the fascia that fixes the back of each lobe to the cricoid cartilage. or fascia. cricothyroid. and an inconstant midline vessel.7 percent). Capsule of the Thyroid Gland Like many other organs.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. It passes downward and anteriorly to reach the superior pole of the thyroid gland. They have been divided into anterior. 1-55.106 The isthmus connecting the two lobes is about 1. and which makes up the stroma of the organ. at.5/24/2014 Print: Chapter 1. The superior parathyroid glands normally lie between the true capsule of the thyroid and the fascial false capsule. or just below the bifurcation of the common carotid artery. superior laryngeal. Arteries Two paired arteries. and terminal branches of the artery for the blood supply of the thyroid and parathyroid glands. This is the false capsule. Gray SW.42:639-644. 3 cm at its greatest width. supply the thyroid (Fig. Am Surg 1976.uni-plovdiv. A minute epithelial tube or fibrous cord. the lowest voluntary part of the pharyngeal musculature. http://web. with permission. Vascular Supply The thyroid gland competes with the adrenal glands for having the greatest blood supply per gram of tissue. 1-56): the infrahyoid. or lying on the outer surface of the fascia. almost always extends between the thyroid gland and the foramen cecum of the tongue. The thyroid ima artery is only occasionally present. Such thickenings are the ligaments of Berry. permitting enlargement of the thyroid gland posteriorly. and 2-3 cm thick. the thyroid ima artery. Fig. and posterior levators. Akin JT Jr. 1-56). within the thyroid parenchyma. may be smaller than the other (7 percent) or may even be completely absent (1. and innervation. Anteriorly and laterally this fascia is well developed. The false capsule. usually the right. External to the true capsule is a well developed (to a lesser or greater degree) layer of fascia derived from the pretracheal fascia.

the branching pattern of the primary vessel supplying the gland appeared to indicate that its origin was from the superior thyroid artery. In this case. the superior thyroid artery divides into anterior and posterior branches.htm 57/125 . Head and Neck Anatomy: With Clinical Correlations. it is absent in about 5 percent (Hunt et al. The majority of 92 glands (67%) had a single artery of supply.111 The inferior thyroid artery ascends behind the carotid artery and the internal jugular vein. 1/3 had two or more small vessels which entered the gland. On the left. The lowest branch sends a twig to the inferior parathyroid gland and supplies the lower pole of the thyroid gland. 1981. usually anastomosing with a descending branch of the superior thyroid artery. New York: McGraw-Hill.109 observed that an anastomosing vessel from the posterior branch of the superior thyroid artery supplied the superior parathyroid in 45% of cases. but in about 15 percent of individuals it arises directly from the subclavian artery. 1-57). In a study of thyroid glands removed at autopsy from Japanese patients. (Modified from Montgomery RL. the right inferior thyroid artery was replaced by an artery originating from the right internal thoracic artery. passing medially and posteriorly on the anterior surface of the longus coli muscle. or between its branches (Fig.112 The artery is occasionally double.5/24/2014 Print: Chapter 1. The left inferior thyroid artery was replaced by an artery arising from the vertebral artery. The recurrent laryngeal nerve may pass anterior or posterior to the artery. http://web. The anterior branch anastomoses with the contralateral artery. Neck Branches of the superior thyroid artery. Weiglein110 reported a rare variation of blood supply to the thyroid gland. On the right. In the photographs of the specimens. the inferior thyroid artery is absent in about 2 percent of individuals. The upper branch supplies the posterior surface of the gland.). After piercing the prevertebral fascia. From the posterior branch. Nobori et al. INFERIOR THYROID ARTERY The inferior thyroid artery usually arises from the thyrocervical trunk.uni-plovdiv. the artery divides into two or more branches as it crosses the ascending recurrent laryngeal nerve.113 Fig.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. 1-57.) At the superior pole. a small parathyroid artery passes to the superior parathyroid gland.108 the posterior branch anastomoses with branches of the inferior thyroid artery. with permission.

It arises from the brachiocephalic artery. Emerging from the superior pole of the thyroid. E. the superior. MIDDLE THYROID VEIN The middle thyroid vein arises on the lateral surface of the gland at about two-thirds of its anteroposterior extent. Vascular patterns of the thyroid gland. and inferior thyroid veins (Fig. The nerve loops beneath the artery. Its position anterior to the trachea makes it important in tracheostomy. Harlaftis N. A-C. Skandalakis JE.5/24/2014 Print: Chapter 1. The extra vein is inferior to the normal one. Am Surg 1976. The plexus is drained by three pairs of veins. double. Akin JT Jr. Their frequencies are given in Table 1-9. occasionally. middle. Neck Relations at the crossing of the recurrent laryngeal nerve and the inferior thyroid artery. A nonrecurrent nerve is not related to the inferior thyroid artery. according to Montgomery. (Modified from Tzinas S. Droulias C. (Modified from Tzinas S. Veins Veins of the thyroid gland form a plexus of vessels lying in the substance and on the surface of the gland. Common variations. with permission.42:639-644. This vein may be absent or. with permission.htm 58/125 . Gray SW. Vascular patterns of the thyroid gland. Fig.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. or the aortic arch.42:639-644.) THYROID IMA ARTERY The thyroid ima artery is unpaired and inconstant. Am Surg 1976. The inferior thyroid veins are quite variable. Droulias C.) SUPERIOR THYROID VEIN The superior thyroid vein accompanies the superior thyroid artery. It crosses the common carotid artery to open into the internal jugular vein.uni-plovdiv. the vein passes superiorly and laterally across the omohyoid muscle and the common carotid artery to enter the internal jugular vein alone or with the common facial vein. Gray SW. D. Harlaftis N. it http://web. Akin JT Jr. Skandalakis JE. The venous drainage of the thyroid gland. the right common carotid artery. No artery accompanies it. 1-58).41 It may be as large as an inferior thyroid artery or it may be a mere twig. 1-58. It occurs in about 10 percent of individuals.

Edis et al. Am Surg 1976. Neck common carotid artery to open into the internal jugular vein. occasionally. Hollinshead. The extra vein is inferior to the normal one. it has been called the "fourth" thyroid vein.) Fig. the right vein crosses the trachea to enter the left brachiocephalic vein. Each conceptualization is based on the same facts. 1-59. 1-60. Rarely. Fig. INFERIOR THYROID VEIN The inferior thyroid vein is the largest and most variable of the thyroid veins. (Modified from Tzinas S. Harlaftis N.42:639-644. 1-59C).352 B. We will follow that of Hollinshead36 (Fig. The right vein leaves the lower border of the thyroid gland. each is correct. Vascular patterns of the thyroid gland. sometimes forming a common trunk with the left vein. A. http://web. McGregor and DuPlessis.36 All three concepts are correct and based on the same facts. double. passes anterior to the brachiocephalic artery. Gray SW.htm 59/125 . Akin JT Jr. Lymphatics Several broad patterns of lymphatic drainage of the thyroid gland have been proposed (Fig. Skandalakis JE. This vein may be absent or. Three concepts of the lymphatic drainage of the thyroid gland. 1-60. the right and left sides are usually asymmetric. The importance of these middle thyroid veins is in their vulnerability during thyroidectomy. and enters the right brachiocephalic vein. 1-59). This common trunk is called the thyroid ima vein. The actual drainage is shown in Fig. Droulias C.76 C.5/24/2014 Print: Chapter 1.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.uni-plovdiv. The left vein crosses the trachea to enter the left brachiocephalic vein. with permission.

Between these two groups. with permission. After the description of Rouviere.uni-plovdiv. Burgess MA. Sherman SI.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Median Inferior Drainage Several lymph vessels drain the lower part of the isthmus and the lower medial portions of the lateral lobes.114 In neither the orbit nor the eye itself can lymphatic vessels be demonstrated.115 The immediate cause of exophthalmus associated with thyroid disease is the enlargement of the extraocular muscles. a posterior ascending trunk from the upper part of the lobe reaches the retropharyngeal nodes. or thoracic duct without passing through a lymph node. Lymph node groups at the highest risk for regional metastasis from differentiated thyroid carcinoma are shown in Fig. some vessels pass laterally. especially the inferior rectus and inferior oblique.htm 60/125 . Am Surg 1976. Right and Left Lateral Drainage Lymphatic trunks arise from the lateral border of each lobe. such vessels drain into the right subclavian vein. These vessels pass upward in front of the larynx to end in the digastric lymph nodes. 1-61.) PATTERNS OF DRAINAGE Median Superior Drainage Three to six vessels arise from the superior margin of the isthmus and from the medial margins of the lateral lobes. (Modified from Callender DL. Droulias C. Some vessels may enter one or more prelaryngeal ("Delphian") nodes just above the isthmus.5/24/2014 Print: Chapter 1. METASTATIC SPREAD A representation of lymph node regions of importance for management of thyroid carcinoma is seen in Fig. Gray SW. Occasionally. Thyroid antigen or antigen-antibody complexes reaching the eye from the thyroid gland produce an autoimmune response in the extraocular muscles.116 Posterior Drainage Posterior lymphatic vessels arise from the inferomedial surfaces of the lateral lobes to drain into nodes along the recurrent laryngeal nerve. 1-61. Vascular patterns of the thyroid gland. Fig. Harlaftis N. Akin JT Jr.359 (Modified from Tzinas S. Secondary drainage may be to upper jugular nodes on either side or to pretracheal nodes below the thyroid by a vessel passing from the Delphian nodes downward over the front of the thyroid.42:639-644. Neck The lymph nodes receiving drainage from the thyroid gland. Cancer of the http://web. or posteriorly to the carotid sheath to reach the lymph nodes of the internal jugular chain. 1-62. Goepfert H. jugular vein. Gagel RF. It has been suggested that there is a connection between the lymphatic drainage of the superior thyroid artery and the orbit by way of the jugular chain of cervical lymph nodes. Inferiorly they follow the inferior thyroid artery. Superiorly they pass upward with the superior thyroid artery and vein. Occasionally. Skandalakis JE. They follow the inferior thyroid veins to end in the pretracheal and brachiocephalic nodes. anteriorly. Lymph node regions of importance for management of thyroid carcinoma.

485-515. 1996. Am J Otolaryngol 1994. lower jugular nodes were positive. Gagel RF. Table 1-5.) Fig.) A study by Gemsenjäger et al. based on more than 1.000 patients of Shaha et al. Cancer of the thyroid. Feind118 found metastatic involvement of middle jugular lymph nodes in 85 of 111 specimens from patients with thyroid carcinoma. Shaha et al.117 of patients with differentiated thyroid carcinoma concluded that papillary carcinoma pT1-3 N0 M0 and minimally invasive follicular carcinoma without nodal or distant metastasis can be adequately treated with hemithyroidectomy or total thyroidectomy only and without radioiodine. middle. Callender DL. Incidence of Metastasis in Thyroid Carcinoma Nodal Metastasis Distant Metastasis Papillary 61% 10% Follicular 30% 22% Hurthle cell 21% 33% Source: Data from Shaha AR.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. with permission. Diagram illustrating lymph node groups at highest risk for regional metastasis from differentiated thyroid carcinoma. Patterns of nodal and distant metastasis based on histologic varieties in differentiated carcinoma of the thyroid. Goepfert H. In 67 of these. But in thyroid surgery the recurrent and superior laryngeal nerves of the parasympathetic (vagus) system (which play no role in the innervation of the gland) are of utmost importance. Read an Editorial Comment Innervation The thyroid gland is innervated by the sympathetic system from the superior. Submandibular and mediastinal nodes were rarely affected. http://web.119 summarizes the incidence of nodal metastasis and distant metastasis in differentiated thyroid carcinoma. Table 1-5. The right recurrent nerve branches from the vagus as it crosses anterior to the right subclavian artery. 1-62. Loree TR. p. so we consider them here. Shah JP. with permission. Philadelphia: WB Saunders.htm 61/125 . (Modified from Callender DL. Suen JY (eds). and inferior ganglia of the cervical chain. (Modified from Goepfert H. Recurrent Laryngeal Nerves (Inferior Laryngeal) NORMAL ANATOMY The right and left recurrent laryngeal nerves are intimately related to the thyroid gland. while all the other tumors such as invasive follicular cancer were treated adequately with total bilateral lobectomy and radioiodine. Burgess MA.15:167-179.5/24/2014 Print: Chapter 1. In: Myers EN. Cancer of the Head and Neck (3rd ed). Differentiated thyroid cancer – papillary and follicular carcinoma. crosses behind the right common carotid and ascends in or near the tracheoesophageal groove. It passes posterior to the right lobe of the thyroid gland to enter the larynx behind the cricothyroid articulation and the inferior cornu of the thyroid cartilage. Sherman SI. concluded that the risk of nodal and distant metastasis varies considerably based on individual histologic variety. Am J Surg 172:692-694. 1996. 1-63B) loops around the subclavian artery from posterior to anterior. Neck Lymph node regions of importance for management of thyroid carcinoma..uni-plovdiv. The right recurrent nerve (Fig.

The laryngeal nerve arises from the vagus nerve and passes under and behind the sixth aortic arch." D. Normal embryo with third. Therefore. It loops under the ligamentum arteriosum and the aorta. The embryonic aortic arches and the "recurrence" of the laryngeal nerve. C. the nerve passes to the larynx without "recurring. VARIATIONS Several variations may occur in the courses of the recurrent nerves. but passes medially almost directly from its origin to the larynx without looping under the subclavian artery (Fig. Am Surg 1976. On the right.uni-plovdiv. In the presence of a right aortic arch. thyroid surgery must include identification and preservation of the recurrent laryngeal nerve and all of its divisions. B. on the left. it passes under the ligamentum arteriosum. Harlaftis N.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Even less common is a nonrecurrent left nerve in the presence of a right aortic arch and a retroesophageal left subclavian artery (Fig. 1-63.117 recurrent laryngeal nerves. In an earlier version of this research.) The left recurrent nerve arises where the vagus nerve crosses the aortic arch. 1-63C). the right recurrent nerve arises normally from the vagus. the laryngeal nerve passes under the subclavian artery. This anomaly is asymptomatic. fourth. In these cases. Akin JT Jr. Normal adult.htm 62/125 . Neck Fig."121 In about 1 percent of patients. Bilateral nerve bifurcation was observed in 170 patients. 1-63D). They reported that 747 (63%) bifurcated or trifurcated more than 0. (Modified from Skandalakis JE.5/24/2014 Print: Chapter 1. http://web. and sixth aortic arches present.42:629-634. with permission. A. Both nerves cross the inferior thyroid arteries near the lower border of the middle third of the gland. Recurrent laryngeal nerves. C and D are encountered in less than 1 percent of specimens. these authors wisely concluded that "extralaryngeal branches of the recurrent laryngeal nerve are not an anatomic rarity. All serve to increase the possibility of injury to the nerve during thyroid surgery. the left nerve passes directly to the larynx. Droulias C. the right nerve loops under the arch. and the thyroid surgeon will rarely be aware of it prior to operation. Tzinas S. In the presence of a retroesophageal right subclavian artery. the right subclavian artery arises from the descending aorta and passes to the right behind the esophagus. just distal to the origin of the left subclavian artery from the aortic arch. and ascends in the same manner as the right nerve. Gray SW.5 cm from the cricoid cartilage. Katz and Nemiroff 120 visualized 1.

) Read an Editorial Comment The senior author of this chapter (JES) feels very strongly that the "recurrent laryngeal nerve" should be named or renamed the inferior laryngeal nerve. (Modified from Skandalakis JE. the recurrent laryngeal nerve ascends behind the pretracheal fascia at a slight angle to the tracheoesophageal groove. the nerve passes just behind the cricothyroid joint and can be easily identified. The course of the recurrent laryngeal nerve at the thyroid gland in 102 cadavers. http://web. In about half of the specimens. as in other anatomical locations.uni-plovdiv.42:629-634. Neck In the lower third of its course. In the other half. Droulias C.123 Fig. A. In the middle third of its course. Even in the case of a unilateral single trunk. Akin JT Jr. the nerve may lie in the groove. 1-64. Am Surg 1976.122 examined the course of the recurrent laryngeal nerve in 102 cadavers (204 sides). the nerve lay in the tracheoesophageal groove. Lateral view. Variations. About half the nerves were found in the groove between the trachea and the esophagus. Skandalakis et al. Tzinas S.htm 63/125 .. with permission. the surgeon can rely on precise and consistent landmarks in this part of the body. In 8 of the 204 sides. Other workers have found a slightly higher percentage of intraglandular nerves. medial to the suspensory ligament of the thyroid gland (ligament of Berry). within the ligament. Thus..were mainly limited to the level of the extralaryngeal division of the inferior laryngeal nerve. a few lay posterior (paraesophageal).5/24/2014 Print: Chapter 1. Gray SW. Recurrent laryngeal nerves. the nerve lay within the gland (Fig. B.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. most were anterior to the groove (paratracheal). Cross-sectional view. We quote from Schweizer and Dörfl124: [I]t is particularly interesting for laryngeal surgeons to notice the minor variability of branching of the inferior laryngeal nerve and of its mode of entrance into the hypopharynx. Harlaftis N. 1-64). or within the substance of the thyroid gland.

with permission. Akin JT Jr."136 At the other extreme are those who would require demonstration of the nerve by direct stimulation during laryngoscopic observation of the vocal cords. Marchesi et al.4 9.ansa cervicalis) of the injured recurrent nerve. Miyauchi et al.2%) than when it was exposed (1.0 100. This double nerve presentation has not been described before.140 advised that the best way to locate the recurrent laryngeal nerve during thyroidectomy is the Zuckerkandl's tuberculum. Sturniolo et al.0 100.8 20. and extreme rarity on the left side. identification. EXPOSURE Exposure of the recurrent nerve during any procedure on the thyroid is a sound surgical principle and should be done wherever possible.uni-plovdiv. or stripping the connective tissue is all that is necessary. Droulias C.3 24. which is located on the lateral portion of each of the thyroid lobes. and cervical trachea.6 50. Gray SW. A series by Skandalakis et al.139 If the nerve is not found.137 We believe that visual identification. but simple exposure will not destroy it. http://web. and (4) following the course of the nerve with care.5/24/2014 Print: Chapter 1. the left nerve was usually behind the artery (64 percent). It is most vulnerable when it traverses the thyroid parenchyma. supply the larynx beneath the cords.138 noted a significantly higher rate of injury to the recurrent laryngeal nerve when it was not identified (5.5 3.0 100. or between the branches of the artery. and maximum phonation improved. 1-65.125 Lekacos et al.130 reported an occurrence rate of 0.4 Nerve between branches of artery 48. It may lie anterior or posterior to. a nonrecurrent nerve should be suspected.135 At one time the recurrent nerve was considered so delicate that "if a recurrent laryngeal nerve is seen during thyroidectomy. The recurrent laryngeal nerve forms the medial border of a triangle bounded superiorly by the inferior thyroid artery and laterally by the common carotid artery.6 63. Table 1-6. Avisse et al.0 Source: Skandalakis JE. or such a nerve may loop around the artery (Fig. Pelizzo et al. increased bleeding.8 Nonrecurrent nerve and other – 0. with avoidance of traction. Table 1-6 shows the relative incidence of the types of crossing. Unless one is aware of this possibility. Kreyer and Pomaroli127 reported an anastomosis between the external branch of the superior laryngeal nerve and the recurrent laryngeal nerve. Tzinas S. (2) total extracapsular thyroidectomy.34% for a nonrecurrent inferior laryngeal nerve on the right side. This maneuver aided safe dissection in the region of the inferior thyroid artery. 1976. cervical esophagus.0 100. having identified only a small recurrent branch.133 reported good results with simple neurorrhaphy or with graft (vagus nerve . From their investigation of 803 goiter operations and a literature search. According to Procacciante and colleagues.htm 64/125 .5 37. 1-57A-C. both a nonrecurrent nerve and an additional recurrent branch were present on the right side. Fibrosis. Steinberg et al. The recurrent laryngeal nerve crosses the inferior thyroid artery at the middle third of the gland. compression. They report seven cases of nonrecurrent laryngeal nerve. In two of these cases an aberrant right subclavian artery coexisted with a nonrecurrent inferior laryngeal nerve. the surgeon must be prepared for any configuration of artery and nerve. 1-65) Fig. The recurrent laryngeal nerve is safest and least visible when it lies in the tracheoesophageal groove. No one pattern can be considered "normal".bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Sanders et al. The three major types of crossings were shown previously in Fig. 1-57E). Complete anatomic dissection is not required. Neck precise and consistent landmarks in this part of the body. Am Surg 42(9):629-634. Harlaftis N. We emphasize the need for a complete nerve identification technique..000 thyroidectomies. The recurrent laryngeal nerve. and exposure of the nerve itself. it must be identified and protected before the ligament is divided. pharynx. Relationship of Recurrent Laryngeal Nerve and Inferior Thyroid Artery Per Cent Frequency 102 Cadavers 1246 Cases From Literature Relation Right Left Both Sides Both Sides Nerve anterior to artery 31. the surgeon must avoid the areas in which it may be hidden. together with sympathetic nerves. 1-57D). especially on the right.129 after the recurrent laryngeal nerve is made taut by upward and medial traction of the thyroid. and according to these authors is the constant anatomic landmark when present (Fig. when present) may pass directly to the larynx with no relation to the inferior thyroid artery (Fig. and emphasize the diagnostic accuracy of angio-MR for the anatomic identification of the vascular anomaly that invariably occurs with the nerve malformation. Their 8 patients recovered from hoarseness. The nonrecurrent nerve (left or right.1 Nerve posterior to artery 19. as in other anatomical locations.128 emphasized that the secret to avoiding injury to the recurrent laryngeal nerve during thyroid surgery is as follows: (1) deep knowledge of the surgical anatomy of the thyroid region.132 who found seven cases of nonrecurrent laryngeal nerves in 1.0 26. If the nerve cannot be found readily.6 21. it may be palpated caudally to the inferior pole of the gland. it is injured.6 1.131 reported 17 cases of a right nonrecurrent inferior laryngeal nerve. Postoperative exploration for hemorrhage also is associated with a higher risk of nerve injury. The nerve can be identified where it enters the larynx just posterior to the inferior cornu of the thyroid cartilage.122 showed that the right nerve most frequently lay between arterial branches (48 percent). Jatzko et al. and lack of clear anatomic relationships are responsible for most nerve injuries.126 reported that most recurrent laryngeal nerves (approximately 80%) are located either posterior to or between the branches of the inferior thyroid artery. Where it runs in the suspensory ligament of the thyroid. (3) a thorough search.2%). reported the following: In two of these seven cases.7 41. one might inadvertently injure the major nonrecurrent trunk.134 stated that branches of the recurrent laryngeal nerve (motor as well as sensory).

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Fig. 1-65.

Print: Chapter 1. Neck

Zuckerkandl's tuberculum size. 0, unrecognizable; 1, only a thickening of the lateral edge of the thyroid lobe; 2, smaller than 1 cm; 3, larger than 1 cm. (Modified
from Pelizzo MR, Toniato A, Gemo G. Zuckerkandl's tuberculum: an arrow pointing to the recurrent laryngeal nerve (constant anatomical landmark). J Am Coll Surg
1998;187:333-336, 1998; with permission.)

The tubercle of Zuckerkandl is the most posterior extension of the lateral lobes of the thyroid gland at the level of the ligament of Berry141,142 (Fig. 1-66).
Fig. 1-66.

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The region of the tubercle of Zuckerkandl (the most posterior extent of the thyroid lobe) and the distal course of the recurrent laryngeal nerve (RLN). The relation of
the RLN to the remaining remnant of thyroid and mechanism for possible RLN injury are shown. (Modified from Thompson NW. Thyroid gland. In: Greenfield LJ (ed).
Surgery: Scientific Principles and Practice (2nd ed). Philadelphia: Lippincott-Raven, 1997, pp. 1283-1308; with permission.)

To digress for a moment, I (JES), the senior author of this chapter, would like to point out that never in my 50 years in the anatomy lab and operating room
did I notice the tubercle of Zuckerkandl. To my embarrassment and frustration, I had not heard of this specific protuberance of the thyroid lobe until I read
the previously mentioned excellent publication by Pelizzo et al.140
In the lower portion of the course of the recurrent laryngeal nerve, the nerve can be palpated as a tight strand over the tracheal surface. There is more
connective tissue between the nerve and the trachea on the right than on the left.

Superior Laryngeal Nerve
The superior laryngeal nerve arises from the vagus nerve just inferior to its lower sensory ganglion just outside the jugular foramen of the skull. The nerve
passes inferiorly, medial to the carotid artery. At the level of the superior cornu of the hyoid bone it divides into a large, sensory, internal laryngeal branch
and a smaller, motor, external laryngeal branch, serving the cricothyroid muscle143 and the cricopharyngeus. The point of division is usually within the
bifurcation of the common carotid artery (Fig. 1-67).
Fig. 1-67.

Branching of the superior laryngeal nerve and the carotid arteries. A, The internal branch crosses the external carotid artery above the origin of the lingual artery. B,
The internal branch crosses below the origin of the lingual artery. C, The nerve divides medial to the external carotid artery. (Modified from Droulias C, Tzinas S,
Harlaftis N, Akin JT Jr, Gray SW, Skandalakis JE. The superior laryngeal nerve. Am Surg 1976;42:635-638; with permission.)

Sun and Dong144 dissected 60 adult cadavers (120 superior laryngeal nerves) and reported the morphology and topography of the superior laryngeal nerve,
its branches, its anastomoses with the cervical sympathetic, and its relations to the thyroid gland. An anastomotic loop connecting the cervical sympathetic
chain and the distal laryngeal nerve was present in 111 of the 120 cases. The morphology of this loop made it possible to define five different types. Figures
1-68 and 1-69 are from their interesting paper, and we urge all surgeons who perform thyroid surgery to read it.
Fig. 1-68.

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The sketch of the coronal section of the larynx shows the superior laryngeal nerve trunk(s) in the environment of the sternothyroid-laryngeal triangle, which is
bounded laterally by the sternothyroid muscle, medially by the inferior pharyngeal constrictor and cricothyroid muscles, and inferiorly by the superior pole of the
thyroid gland. a, single nerve trunk, 89 sides (74.2%); b, single nerve trunk, 1 side (0.8%); c, double nerve trunks, 24 sides (20%); d, double nerve trunks, 4 sides
(3.3%); e, triple nerve trunks, 1 side (0.8%); f, quadruple nerve trunks, 1 side (0.8%). (Modified from Sun SQ, Dong JP. An applied anatomical study of the superior
laryngeal nerve loop. Surg Radiol Anat 1997;19:169-173; with permission.)

Fig. 1-69.

Variations of laryngeal nerves. Type I, V-shaped in 94 sides (78.3 ± 3.8%). Type II, U-shaped in 8 sides (6.7 ± 2.3%). Type III, Mixed in 14 sides (11.7 ± 2.9%).
Type IV, Juxtaposed-double in 1 side (0.8 ± 0.8%). Type V, Juxtaposed-triple in 1 side (0.8 ± 0.8%). SLN, superior laryngeal nerve; ILN, internal laryngeal nerve;
SCG, superior cervical ganglion; CT, communicating twig; ELN, external branch of laryngeal nerve; CTB, cricothyroid muscle branch; GB, thyroid branch. (Modified from
Sun SQ, Dong JP. An applied anatomical study of the superior laryngeal nerve loop. Surg Radiol Anat 1997;19:169-173; with permission.)

To prevent iatrogenic injury of the superior laryngeal nerve during surgical dissection near the thyroid apex in the neck, el-Guindy and Abdel-Aziz145
recommended anatomical localization of the nerve in the viscerovertebral angle, functional identification, and post-operative analysis.
INTERNAL LARYNGEAL NERVE

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http://web.5/24/2014 INTERNAL LARYNGEAL NERVE Print: Chapter 1. together with the superior thyroid vein and artery. It also provides parasympathetic fibers for the glandular elements and some taste fibers that supply taste buds around the epiglottis. The nerve then passes beneath the lower border of the thyrohyoid muscle to continue inferiorly to innervate the cricothyroid muscle. especially for patients with large goiters.htm 68/125 . Neck The internal laryngeal branch pierces the thyrohyoid membrane with the superior laryngeal branch of the superior thyroid artery to enter and supply the larynx. advised nerve identification in the operating room. Cernea et al.147 suggested that in some individuals a branch of the external laryngeal nerve may also contribute to the innervation of the thyroarytenoid muscle and to the sensory supply of the vocal fold of the larynx. with permission.) EXTERNAL LARYNGEAL NERVE The external laryngeal branch. Cernea et al. identification occurs only in those cases where a greatly enlarged upper pole of the thyroid gland rises above the superior border of the thyroid cartilage (Fig. Fatigue.146 An investigation by Wu et al.150 Fig. Skandalakis JE. The internal laryngeal nerve provides general sensory fibers to the larynx and the area of the piriform recess of the laryngopharynx. passes under the sternothyroid muscles. causing a permanent voice change for professional vocalists. In addition to its contribution to phonation. (Modified from Droulias C. Harlaftis N. The superior laryngeal nerve. posterior and medial to the vessels. Cernea and colleagues have also presented further findings about the surgical anatomy of the superior laryngeal nerve. 1-71.148 stated that injury to the external branch of the superior laryngeal nerve will most likely endure. The internal branch is rarely identified by the surgeon. Tzinas S. also. They postulated that the communicating branch of this nerve might represent the nerve of the 5th embryonic branchial arch.149.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Fig. Am Surg 1976. 1-70.42:635-638. 1-70).uni-plovdiv. Gray SW. The topographic anatomy and relations of the nerves and thyroid vessels are presented in Figure 1-71. the cricothyroid muscle plays a major role in the overall regulation of breathing by its control of expiratory resistance and flow. Akin JT Jr. Relationship between the (A) internal and (B) external branches of the superior laryngeal nerve with the superior thyroid artery and the upper pole of the thyroid gland. is common after injury to the external branch of the superior laryngeal nerve.

In about 25 percent of individuals. which is a thin layer of connective tissue. thyroglobulin. or C cells. with permission. Type 1. Nerve crossing the vessel below the plane. and release of thyroid hormone into the blood and lymphatics. TSH. or C cells. they are separated by thin connective stroma which is rich in both lymphatic and blood vessels. PHYSIOLOGY The follicular cells of the thyroid gland produce the thyroid hormones thyroxine (T 4) and triiodothyronine (T 3). The parafollicular. DIT. St. The follicular cells trap and concentrate iodide from that serum. Epithelial cells (cuboidal or squamous) form the thyroid follicles. accumulates within the colloid.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. resorption of thyroglobulin. Another function of the thyroid gland is the secretion of thyrocalcitonin. the nerve lies beneath the fascia together with the vessels. Type 2b. (From Polk HC Jr. http://web. According to Ross and Reith. Nerve crossing the vessels less than 1 cm above the plane. MIT. Nishio S.151 HISTOLOGY The thyroid gland is surrounded by the thyroid capsule. The synthesis and secretion of thyroxine (T4 ) and triiodothyronine (T3 ). Small bundles of nerves are present.uni-plovdiv. Gardner B. The final product. Figures 1-72 and 1-73 illustrate the synthesis of the hormones of the thyroid gland and their regulated secretion. can be found in the connective stroma between the follicles or in the follicular epithelium. which is the product of the parafollicular or C cells.152 the follicular cells are responsible for the following actions: synthesis of thyroglobulin. Am J Otolaryngol 1995. Type 2a. Characteristically. diiodotyrosine. with permission. Each follicle has two types of cells: follicular and parafollicular. 1-73. The nerve crosses the superior thyroid vessels 1 or more centimeters above a horizontal plane passing the upper border of the superior thyroid pole. according to the potential risk of iatrogenic lesion during a hypothetical thyroidectomy. which is subdivided into several lobules. hydrolysis of thyroglobulin. Neck Classification of the external branch of the superior laryngeal nerve. Hojaij FC. storage of thyroglobulin. Fig.) In most patients. while the external laryngeal nerve lies between the fascia and the inferior pharyngeal constrictor muscle.5/24/2014 Print: Chapter 1. There is thus a plane of dissection between the vessels and the nerve.16:307. iodination. the blood vessels lie within the visceral compartment of the neck beneath the pretracheal fascia. There is a colloidal gelatinous collection in the center of the follicle. Identification of the external branch of the superior laryngeal nerve (EBSLN) in large goiters. 1995. Louis: Quality Medical.) Fig. 1-72.htm 69/125 . monoiodotyrosine. thyroid-stimulating hormone. From the capsule. (Modified from Cernea CR. Basic Surgery (5th ed). several septa extend within the thyroid parenchyma. they contain several secretory granules. Stone HH.

St. 1-74.) THYROID SURGERY The surgical procedures for thyroid pathology are total bilateral lobectomy.5/24/2014 Print: Chapter 1. Recently.156 reported that the procedure of choice for bilateral benign multinodular goiter is total thyroidectomy. long-acting thyroid stimulator.154 "Minimally invasive thyroidectomy utilizing endoscopic techniques may also affect the practice of thyroid surgery. FTI. We agree with the advice of Bliss and colleagues. Delbridge et al. Gardner B. total unilateral with partial contralateral lobectomy. since that procedure obviates recurrent goiter and a need for secondary thyroidectomy. Neck The physiologic regulation of thyroid hormone secretion and the thyroid tests which measure these parameters. Basic Surgery (5th ed). (Modified from Polk HC Jr. TRH. thyroid-stimulating immunoglobulins." We present the valuable flowchart of Johns155 for management of solitary thyroid nodules (Fig. 1995. and partial or subtotal lobectomy (unilateral or bilateral). There is much controversy as to which is the most appropriate choice for each patient and each disease. The surgical profession agrees to disagree about all these procedures. TSI. minimally invasive thyroid surgery has been performed successfully. TBG. Fig. Louis: Quality Medical. Ferzli et al. http://web.htm 70/125 . thyroxine-binding globulin. understanding the surgical anatomy of the thyroid gland and its possible variations is paramount to safe and effective surgery. free thyroxine index. with permission. Even so.153 reported feasible and safe mini-thyroidectomy on glands no larger than 7 cm. TSH. LATS. Stone HH.uni-plovdiv. 1-74). thyrotropin-releasing hormone. thyroidstimulating hormone.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.

Ron et al. Visset J. Le Bodic MF. In papillary carcinoma of the thyroid. fine-needle aspiration.5/24/2014 Print: Chapter 1. since proportionally few patients treated with irradiation develop nodal recurrence of metastases.1%) 12 (16.161 presented tables showing localization of lesion in papillary thyroid carcinoma (Tables 1-7.9%) Subdigastric 20 (27.7%) Supraclavicular 26 (36. Ipsi subdig: ispilateral http://web. with permission. smaller nodes also have micrometastases. Curr Ther Otolaryngol 1987. World J Surg 1999.160 stated that microscopic involvement of the cervical lymph nodes is 80%.3:226-229. Node Involvement According to Localization of the Tumor in the Thyroid Lobe No. in Node-Positive Patients Node Localization Ipsilateral (n=71) Contralateral (n=30) Paratracheal 60 (83. radiation absorbed dose. RAD. Ipsi supraclav: ipsilateral supraclavicular nodes.1%) 5 (6. surgery is used infrequently. Localization of cervical node metastasis of papillary thyroid carcinoma. American endocrinologists advise antithyroid drugs for young individuals. Clark.159 found papillary carcinoma to be the largest group. but iodine 131 for adults.3%) 25 (34. Table 1-8. accounting for 39.157 treatment of hyperthyroidism is still somewhat controversial.uni-plovdiv.7%) Midjugular 44 (61. they should be removed. (2) Therapeutic functional modified radical neck dissection should be performed. Sagan C. TSH. Localization of Node Involvement No.23:970974. thyroid-stimulating hormone. European and Japanese endocrinologists are more likely to recommend antithyroid drugs regardless of the patient's age. which is considered in the following section on the parathyroid gland. Hamy A. The solitary thyroid nodule.162 in his invited commentary. 1-8). Paineau J. since with palpable metastatic lymph nodes.8%) Source: Mirallié E. Neck Management flowchart for patient with solitary thyroid nodule. made the following recommendations: (1) The surgeon should look for nodes in the central neck. (Modified from Johns ME.5% They reported that this type of tumor is the least malignant. Table 1-7. FNA. with preservation of motor nerves in toto. All over the world.) Read an Editorial Comment Another surgical dilemma is the treatment of hyperparathyroidism. by Site in Thyroid Lobe Node Upper Third Middle Third Lower Third Diffuse Unknown Isthmic Ipsi paratracheal 9 6 10 18 14 3 Ipsi jugular 6 5 6 15 11 1 Ipsi supraclav 3 3 2 13 5 0 Ipsi subdig 7 1 1 5 5 1 Contralat paratrach 2 4 1 10 8 0 Contralat jugular 1 2 0 7 2 0 Contralat supraclav 0 2 1 2 0 0 Contralat subdig 0 0 1 1 0 0 Ipsi paratracheal: ipsilateral paratracheal nodes.htm 71/125 . with permission. According to Cooper.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.8%) 2 (2. Ipsi jugular: ipsilateral jugular nodes. Skandalakis et al. In a study of 124 cases of malignant tumors of the thyroid. Mirallié et al. if present. Noguchi et al. (3) Prophylactic neck dissection should not be performed. (4) "Berry picking" is useless.158 reported that iodine 131 appears to be safe treatment for hyperthyroidism without significantly increasing the risk of total cancer mortality.

Le Bodic MF. Matsuzuka et al. and debulking surgery (when possible) may produce better local control and. They recommend paratracheal and paraesophageal lymph node clearance at primary operation. with permission." The senior author of this chapter (JES) had only one such case and despite the fact that he cauterized and removed protruding anaplastic thyroid tissue daily and performed a tracheostomy.174 advised transsternal mediastinal lymph node dissection for those with lymph node metastases. isolated metastatic disease to the thyroid gland from nonthyroid primary tumors have been observed. Contralat jugular: contralateral jugular nodes. lymphadenectomy should be included according to Dralle et al. since this procedure is safe and effective. Source: Mirallié E. World J Surg 1999.170 reported that tumor microvascular densities perhaps is a new prognostic indicator for differentiated thyroid carcinoma.167 described primary Hodgkin's disease of the thyroid gland and they found 19 similar cases in the literature.175 stated that bilateral thyroid lobectomy (BTL) for thyroid papillary carcinoma is the preferred initial surgical procedure over unilateral lobectomy (UL) since the rates for local recurrence and nodal metastasis with UL are 14% and 19%. Contralat paratrach: contralateral paratracheal nodes. and lateral anlages. and esophagus) by thyroid carcinoma is a rare occurrence. Sanders and Silverman171 stated that follicular and Hürthle cell carcinoma of the thyroid gland with minimal capsular invasion behave in a benign way. Read an Editorial Comment Chen et al. in the absence of contraindications.5/24/2014 Print: Chapter 1. the patient died a few months after surgery. Hamy A. Ipsi supraclav: ipsilateral supraclavicular nodes. Tarantino et al." Invasion of the cervicovisceral axis (larynx. Smith et al. Nilsson et al. Localization of cervical node metastasis of papillary thyroid carcinoma.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.. cervical reexploration is safe and in selected patients may limit MTC progression. Discussion of this paper included comments on lateral aberrant thyroid tissue.23: 970974. also increased survival rate. Ipsi subdig: ispilateral subdigastric nodes. and the importance of early operation for cure. Gimm et al. Gauger et al.172 stated as follows: "[T]he size of a follicular lesion cannot be used to predict a final diagnosis of follicular carcinoma and is of no value when making intraoperative decisions about the extent of thyroid resection.173 neoplastic spread in this area is more often caused by extrathyroidal growth than by nodal metastasis. possibly.uni-plovdiv.176 We quote from Kebebew et al. Visset J. According to Machens et al. Noninvasive imaging studies were helpful but far from perfect for guiding the reexploration for locoregional residual MTC. monitoring of serum calcitonin and CEA levels. We urge the interested reader to study this article in its entirety. Hermann et al. Surgical ablation followed by adjuvant therapy can provide palliation for selected patients only.165 stated that the role of fine-needle aspiration biopsy as well as flow cytometry for the evaluation of neck adenopathy has not been defined. Contralat supraclav: contralateral supraclavicular nodes.168 advised reoperation in recurrent hyperthyroidism.163 reported that although rare.178 stated that there is currently no curative therapy for patients with anaplastic thyroid carcinoma.177 on reoperation of residual medullary thyroid carcinoma (MTC): Although reoperation in patients with residual MTC rarely results in biochemical cure. For the management of amiodarone-associated thyrotoxicosis.164 recommend preoperative fine-needle aspiration of thyroid tumor as a powerful diagnostic tool for thyroid cancer. and both these types have a similar prognosis. and despite irradiation. compared to 2% and 6% with BTL. including the following: Renal cell carcinoma 5 cases Esophageal adenocarcinoma 1 case Pulmonary squamous cell carcinoma 1 case Gastric leiomyosarcoma 1 case Lingual squamous cell carcinoma 1 case Parotid gland carcinoma 1 case Boyd et al. Hereditary medullary thyroid carcinoma should be treated with prophylactic total thyroidectomy during childhood. Sagan C.and postoperatively.180 suggested that thyroidectomy is more effective than conventional http://web. Lateral cervical node dissection could be beneficial at the time of initial surgical treatment because of the high frequency of residual MTC in the lateral cervical nodes. Read an Editorial Comment Lo et al. Dhar et al. Contralat subdig: contralateral subdigastric nodes.htm 72/125 . doxorubicin pre. Neck Ipsi paratracheal: ipsilateral paratracheal nodes. benign metastasizing goiter.169 reported the following: "Patients with anaplastic carcinoma of thyroid have a dismal prognosis heralding imminent death. indicated that patients with thyroid carcinoma who have dThdPase expression and high tumor vascularity probably will need adjuvant radiotherapy. Ipsi jugular: ipsilateral jugular nodes. trachea. if calcitonin levels are elevated or if children are older than 10 years. While Voutilainen et al. Paineau J. Dhar et al. Hay et al. respectively.166 reported that the rare thyroid lymphoma may be detected by the Southern blot (IgH-JH or IgL-JÎ probes) in approximately 85% of the cases. a study by Hamoir et al. In a study of patients who had undergone primary and reoperative surgery for sporadic medullary thyroid carcinoma.179 suggested that a combination of preoperative hyperfractionated accelerated radiotherapy. but aspiration is reliable for diagnosis of metastatic disease.

making it unrecognizable until it is severed. Am Surg 1976. The middle thyroid vein is short and easily torn. Where the nerve passes between branches of the artery. 1-76. Shimizu et al. 1-75. Skandalakis JE. the vein becomes flattened and bloodless. The authors review the anatomic and embryologic bases and discuss the diagnostic and therapeutic implications of this double anomaly. a branch may escape.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. An aberrant right subclavian artery was present in 2 cases.42:648-656. It follows the upper border of the cricothyroid muscle and membrane (Fig. 1-76). The tear is often at the junction of the middle thyroid vein and jugular vein. (Modified from Akin JT Jr. Avisse et al.131 reviewed 17 cases of right nonrecurrent inferior laryngeal nerve. For well-differentiated thyroid carcinomas invading the trachea. The superior thyroid artery should not be clamped above the upper pole of the thyroid because the external laryngeal nerve may be injured. Fig. The superior pole. 1-75). http://web.) Read an Editorial Comment Separation of the inferior thyroid artery from the recurrent laryngeal nerve requires care.182 reported endoscopic resection of thyroid tumors in 5 patients. Technique of total thyroid lobectomy. should be clamped and ligated (Fig. Neck medical treatment. it will retract. If it is divided accidentally.181 reported that most of the patients with thyroid carcinoma and concurrent hyperthyroidism have small carcinomas. With too much traction of the thyroid gland.htm 73/125 . pyramidal lobe excision.uni-plovdiv. Fig. Bleeding during thyroglossal duct cyst surgery. Such an injury to the vein requires immediate repair. Yang et al. ANATOMIC COMPLICATIONS OF THYROIDECTOMY Vascular Injury Thyroid arteries must be ligated carefully. the individual branches must be ligated and divided separately. or division of a thick thyroid isthmus during thyroid surgery or tracheostomy is most likely due to injury of the cricothyroid artery. with permission. The superior thyroid vessels should be clamped and divided within the substance of the upper pole of the thyroid gland. presenting the danger of an air embolism. together with the artery.5/24/2014 Print: Chapter 1. From their cases and from a review of the literature the authors conclude that this arterial anomaly is always present with right nonrecurrent inferior laryngeal nerve. thus filling the field with blood. Failure to secure these vessels adequately will result in massive hemorrhage. Chao et al. This artery springs from the superior thyroid artery or from its anterior branch. the superior thyroid artery tends to retract. Retraction of the artery can result in a hasty attempt at hemostasis that will injure the recurrent nerve. making hemostasis difficult.183 recommend surgical resection followed by primary reconstruction. If the artery is clamped at the pole. with resulting hemorrhage.

In one. or malignancy. the thyroid was retrosternal. the trachea. the pretracheal fascia. retrosternal thyroid gland showing its relation to the pleura (dotted line). Am Surg 1976. Neck Nerves and arteries of the larynx. Intrathoracic goiter can descend into the anterior or posterior mediastinum. An enlarged. but we have records of two patients in whom pneumothorax occurred. Tzinas S. Droulias C. bringing the thyroid gland close to the pleura (Fig. with permission. The duct can be ligated with impunity. in the other. The true capsule of the thyroid.42:645-647. Skandalakis JE. Though the reported use of this procedure is very limited.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. With total conservative thyroidectomy. 1-77). The trachea and esophagus can be injured in the presence of thyroiditis. delivering the substernal goiter in the neck. and the esophagus can be so fixed to one another that vigorous attempts at separation may perforate the trachea.) Pandya and Sanders184 described a method whereby a Foley catheter was placed beyond the substernal component of the goiter. calcified adenoma. The thoracic duct is rarely injured in thyroidectomy. although injury during radical neck dissection is not unknown. A tracheal perforation may require immediate tracheostomy. Fig. Both anteriorly and posteriorly the two pleurae approach the midline. (Modified from Harlaftis N. Gray SW. Rare complications of thyroid surgery. This procedure was used safely and successfully on two patients. a huge toxic goiter extended far laterally. Organ Injury The pleura is rarely injured.uni-plovdiv. The catheter and its inflated balloon were carefully tractioned upward. and hence each other. Akin JT Jr. lateral view.5/24/2014 Print: Chapter 1. hypocalcemia occurs in 20 to 25 percent of http://web. 1-77.htm 74/125 . perhaps the procedure is sound. thereby preventing the need for a sternotomy. The parathyroid glands are close to the posterior thyroid capsule.

carotid endarterectomy. In radical thyroidectomy.) Fig. Dissection of the right side of the human neck. It is possible that some postoperative neurologic problems attributed to accidental injury of the recurrent laryngeal nerve might have actually resulted from ischemia or edema of the vagus nerve. The large vagal artery (A) receives reinforcing branches (R) from the common (B) and internal (I) carotid arteries. Inadvertent damage to these vessels in carotid endarterectomy may account for injury to the vagus nerve (N) and subsequent vagal palsy. 1-78. Fig. Lord RSA. http://web. the incidence is higher.185. with permission. 1-80. thyroidectomy and carotid arch aneurectomy.uni-plovdiv.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Read an Editorial Comment Nerve Injury Vagus Nerve Fernando and Lord187 presented data to indicate that inadvertent interruption of the vascular supply of the vagus nerve could be the hitherto unsuspected cause of several neurologic problems following thyroidectomy.186 In most of these the drop in calcium (perhaps owing to trauma to the glands) is small and transitory.176:333. 1-79. Neck The parathyroid glands are close to the posterior thyroid capsule. (Modified from Fernando DA. With total conservative thyroidectomy. and 1-81). 1-78.htm 75/125 . Preservation of only one parathyroid gland will avoid the symptoms of hypoparathyroidism. hypocalcemia occurs in 20 to 25 percent of patients. and surgery for correction of aortic arch aneurysms. with similar results (Figs. Ann Anat 1994. 1-79.5/24/2014 Print: Chapter 1. it persists in 1-4 percent of cases. The blood supply of the vagus nerve in the human: its implication in carotid endarterectomy.

thyroidectomy and carotid arch aneurectomy.uni-plovdiv. The blood supply of the vagus nerve in the human: its implication in carotid endarterectomy. with permission. Ann Anat 1994. (From Fernando DA.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. 1-81.) Fig. The vagal artery arising from the inferior thyroid artery lies alongside the vein.176: 333. A large vagal vein (V) drains venous blood to the superior (S) and inferior (I) thyroid veins. Neck Neck dissection of the human. Sutures placed distal to the point of opening of the vagal vein or the commencement of the vagal artery may result in degenerative changes or edema of the vagus with consequent vagal palsy. Ann Anat 1994. with permission. Interruption to these vessels in thyroidectomy may account for vagal damage leading to voice changes. Lord RSA. The prominent vagal vein (V) drains into the inferior thyroid vein. Lord RSA. thyroidectomy and carotid arch aneurectomy. 1-80. The vagus nerve is indicated by N. The vagus nerve is indicated by N. Neck dissection of the human. The blood supply of the vagus nerve in the human: its implication in carotid endarterectomy.176:333.5/24/2014 Print: Chapter 1. http://web.) Fig.htm 76/125 . (Modified from Fernando DA.

one was permanent. and esophageal arteries. Such ligation may include a recurrent nerve more anterior than usual.uni-plovdiv. (Modified from Fernando DA. The type of damage to the vagus nerve is comparable to that of the spinal cord with interruption of radicular branches. common carotid artery by B. Inferiorly. Superiorly. Lord RSA. Recurrent Laryngeal Nerve Vulnerability Cause of Vulnerability Percent Encountered Lateral and anterior location 1. The large vagal artery (A) arises from the inferior thyroid artery.137 Another source of injury is mass ligation of the vessels of the lower pole of the thyroid. The blood supply of the vagus nerve in the human: its implication in carotid endarterectomy. most commonly on the anteromedial side of the nerve. The vagus nerve is indicated by N.5/24/2014 Print: Chapter 1. Recurrent Laryngeal Nerve In a series of thyroid operations in which 217 recurrent laryngeal nerves were involved. bronchial. Damage to these small vessels in thyroidectomies and removal of aneurysms of the aortic arch may also contribute to vagal damage and consequent symptoms of vagal palsy and voice changes.5-15. Most recurrent laryngeal nerve injuries occur "just below that point where the nerve passes under the lower fibers of the inferior constrictor muscle to become intralaryngeal. The specific causes of recurrent laryngeal nerve injury have been evaluated by Chang-Chien190 (Table 1-9).htm 77/125 . the cervical and thoracic parts of the vagus have a single large vagal artery.5-3. In the same series there were three injuries to superior laryngeal nerves. Ligation of the venous drainage of the nerve results in edematous changes and nerve palsy. which is formed by contributions at several levels. In between. This vessel bifurcates into ascending and descending branches. The descending branch receives reinforcing twigs from the aorta. Table 1-9. it is supplied by a branch from the inferior thyroid artery (the main trunk of the vagal artery).0 http://web.0 Tunnelling through thyroid tissue 2.176:333. Holt and coworkers188 found 9 nerve injuries. Vagal palsy follows approximately 27% of carotid endarterectomies."189 The usual cause is a hemostatic stitch.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. thyroidectomy and carotid arch aneurectomy. Fernando and Lord187 also wrote that ligating the inferior thyroid artery close to its origin will interrupt the principal supply to the vagus (which typically arises 2-3 cm from the inferior thyroid's origin).) According to the same authors. the vagus receives a branch from the posterior inferior cerebellar artery. The vagal veins drain into the superior and inferior thyroid veins. Ann Anat 1994. of which 4 were permanent. The nerve should be identified before ligating the inferior thyroid vein. the vagus receives reinforcing twigs directly from the common carotid and internal carotid arteries at 1.5 cm intervals. Neck Dissection of the left side of the neck and thorax. with permission.

with permission. 1980.193 Superior Laryngeal Nerve Lekacos et al. quick vocal fatigue and inability to produce high-pitched sounds. They observed that patients with loss of the external laryngeal nerve complained of voice instability. (3) apparent enophthalmos. High division was recommended by Farquharson and Rintoul198 and Paparella and Shumrick.0+ Data from six series of Chang-Chien Y.133 performed ansa cervicalis-recurrent laryngeal nerve anastomosis in the neck for vocal cord paralysis due to mediastinal lesions. In most cases. which is a rare phenomenon. Thyroidectomy of large goiters will be facilitated by division (high.200 and low division by Stell and Maran. Int Surg 65:23. Surgical anatomy and vulnerability of the recurrent laryngeal nerve. and just above the jugular notch. with difficulty in singing.uni-plovdiv. The affected cord will move toward the midline with time.191 In unilateral recurrent nerve injury. Dysphagia can result from damage to early rising branches of the recurrent laryngeal nerves that supply the esophagus. We believe that the patient should be told that in spite of all precautions.0-3. We agree with the statement of Johns and Rood: .188 Neel and coworkers at the Mayo Clinic 192 examined 202 cases of vocal cord paralysis. 1983. bisecting the angle between the inferior segment of the sternohyoid muscle and the clavicle. Source: Skandalakis JE. or.A thorough understanding of the anatomy of the larynx and the relationships of the laryngeal nerve supply to the intrinsic muscles of the larynx is a prerequisite to adequate localization of the site of lesion in laryngeal nerve injury.197 The surgeon must identify any apparent lymph node related to the vertebral artery and fixed in front of the transverse process of the 7th cervical vertebra. Anatomical Complications in General Surgery. middle or low) of the infrahyoid muscles. Fig. New York: McGraw-Hill.5-15. and even passes between the branches of the superior thyroid artery near the superior pole in 6-14% of cases. resulting in loss of the cough reflex and difficulties with aspiration and clearing the airway. The pathway of these branches is quite variable. tracheostomy becomes necessary. resulting in hoarseness and inability to cough.195 the external laryngeal nerve closely parallels the superior thyroid vessels in about 20% of cases. segmental branches spring from this union. Neck Close proximity to inferior thyroid vein 1. Injury to the superior laryngeal nerve alone can be identified by rotation of the superior glottis to the affected side. According to Durham and Harrison.htm 78/125 . Postoperative hoarseness is not always the result of operative injury to laryngeal nerves. the affected vocal cord is paramedian in position due to tension on the vocal ligament by the cricothyroid muscle. there are two roots which unite. (2) partial ptosis of the upper eyelid. http://web. there is a possibility that there may be some vocal disability following thyroidectomy. rather. Miyauchi et al. Successful management of the patient is based upon an accurate etiologic diagnosis.194 noted 3 cases of superior laryngeal nerve injury after 54 classical high ligations of the superior thyroid artery.0 Fascial fixation 2. Injury to the cervical sympathetic nerve results in Horner's syndrome: (1) constriction of the pupil. 1-82. Voice improves. but is followed by narrowing of the airway. 36 (18 percent) were of various known etiologies. because of the narrowing of the airway produced by unopposed cricothyroid muscles. and by bowing of the vocal cord.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. With bilateral recurrent nerve injury.0-12. and (5) flushing and drying of the facial skin on the affected side. The paralyzed vocal cord may be paramedian (interruption of the recurrent laryngeal nerve alone [Wagner-Grossmann theory]) or intermediate (interruption of the recurrent and superior laryngeal nerves).196 Cervical Sympathetic Chain A sympathetic ganglion can be confused with a lymph node and can be removed when the surgeon operates for metastatic papillary carcinoma of the thyroid. Voice is preserved (not unchanged).5/24/2014 Tunnelling through thyroid tissue 2. From 1 to 2 percent of patients have a paralyzed vocal cord prior to thyroid operation. They reported excellent improvement in phonation without vocal cord movement. of which 153 (76 percent) followed thyroidectomy. (4) dilatation of the retinal vessels. The sternohyoid and sternothyroid muscles are innervated by branches that spring after the union of the upper descendent root (C1) and the lower descendent root (C2. Johns and Rood196 discussed classification of the paralyzed vocal cord. Gray SW. We strongly advise the general surgeon to have an indirect laryngoscopy performed prior to thyroidectomy. Loss of the superior laryngeal nerve leaves the tissues of the larynx and piriform recesses insensate. The expectation is that injury to the ansa cervicalis will thus be avoided.201 The formation and location of the ansa cervicalis is variable. With unilateral injury to both the recurrent laryngeal and superior laryngeal nerve the affected cord is in an intermediate position. In their excellent monograph. All but one recovered within a year. therefore there is no "typical" segmental innervation of the infrahyoid muscles. In one of our patients. No injuries were recorded in 227 other cases in which the branches of the superior thyroid artery were ligated at the superior pole.199 middle division by Wilson. Scanlon and colleagues186 reported a series in which 6 of 245 patients who had undergone total thyroidectomy experienced recurrent laryngeal nerve paralysis.0 Arterial fixation 5. and 13 (6 percent) were of idiopathic origin. .5-2.5 Print: Chapter 1. . Rowe JS Jr. inferior cervical and first thoracic ganglia were fused to form a nodelike structure that was removed. The entrance of the motor branch of these two muscles is characteristically in the vicinity of the thyroid cartilage. 1-82). C3) of the ansa cervicalis (Fig. We have seen a singular root in one case. The results of injury to the recurrent laryngeal nerve and the external branch of the superior laryngeal nerve have been outlined by Esmeraldo and coworkers.

1-83. The muscles should ordinarily be divided high to protect their nerve supply. For all practical purposes we do not know the topography of the union and the pathway of the branches of the ansa cervicalis in a given patient. Fig. Therefore. C2 and C3 via the hypoglossal nerve (Fig. http://web. 1-83). By all means we agree with Beahrs et al. Neck A plan of the right hypoglossal nerve and ansa cervicalis.5/24/2014 Print: Chapter 1.htm 79/125 .bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.23 that the integrity of these four muscles should be preserved. we must prepare carefully for facilitating thyroidectomy by unilateral or bilateral division of the four infrahyoid or strap muscles which are innervated by the ventral rami of C1.uni-plovdiv.

202. the derivatives of the third pouch become the inferior parathyroids (parathyroids III). The accuracy of localization was increased up to 84. but parathyroids III are closely associated with the thymus gland derived from the ventral portion of the third pouch. Fig.6% Permanent recurrent laryngeal nerve palsy 1.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.uni-plovdiv. middle ear. There is also the possibility that some normally transient structures will persist into adulthood. and scintiscanning had overall accuracy of 78. 1-84. Postoperative complications were as follows: Transient hypoparathyroidism 5. These clefts and pouches.204 reported that the uncommon procedure of reoperative thyroid surgery can be safely performed with little morbidity to the patient. While our postoperative observations might have been superficial. and external auditory canal. Preoperative localization techniques in patients with primary HPTH and previous thyroid surgery have high accuracy. and its branches to the infrahyoid muscles. Although transitory. provided precise operative rules are respected.7% We quote from Profanter et al. compose the branchial apparatus. we never noticed any changes in voice. Occasionally. we believe that this 2% rate is low enough to allow reoperation whenever it is necessary.5/24/2014 Print: Chapter 1. However. the point of division varies depending on the size of the megathyroid. As a result of their subsequent migration. the apparatus leaves some normal derivatives: the thyroid and parathyroid glands. which carry a high risk of recurrent laryngeal nerve injury. In our practices we occasionally divide the muscles. ultimobranchial body. We strongly advise the interested student to carefully read the papers of Yerzingatsian.directed operative strategy. together with the branchial arches between. but it may be frustrating for the surgeon.7% Transient recurrent laryngeal nerve palsy 2. its roots.2% Permanent hypoparathyroidism 1.htm 80/125 .6% if both diagnostic procedures were applied. the hyoid bone and laryngeal apparatus malfunction and impair swallowing. The parathyroid glands develop as epithelial thickenings of the dorsal endoderm of the third and fourth branchial pouches. We quote from Menegaux et al.203 Chao et al. and it was 100% if scintiscanning was used.205 on primary hyperparathyroidism (HPTH): Sonography had an overall accuracy to correctly localize enlarged parathyroid glands of 80%. Both primordia descend from their level of origin. parathyroids III become encapsulated with the thymus and may be carried into the mediastinum. When these four muscles are paralyzed. . thymus. 1-84). In patients with normal thyroid residues the accuracy of sonography was 85. This allows for an imaging. This is of no significance to the patient. Internally there are five branchial pouches of endoderm. PARATHYROID GLANDS EMBRYOGENESIS Normal Development In the fifth and sixth weeks of gestation the embryonic pharynx is marked externally by four branchial clefts of ectoderm. or mastication.7%. . eustachian tube. Neck The ansa cervicalis. while those of the fourth pouch become the superior parathyroids (parathyroids IV) (Fig. This association usually ends in the eighth week. about secondary thyroidectomy:206 The permanent complication rate is higher in thyroid reoperations than in primary thyroid operations.6%. leaving the parathyroid gland near the level of the lower border of the thyroid gland. deglutition. thus preventing unnecessary bilateral neck explorations. http://web.

The glands may be found at any point along those pathways.42:621-628.5/24/2014 Print: Chapter 1.. 1-85. Lundgren et al. Embryological considerations of thyroid surgery: Developmental anatomy of the thyroid. Fig.211 advised preoperative parathyroid localization with technetium-99m-sestamibi scan. shape. Am Surg 1976. (Modified from Gray SW. The LobdellDiGeorge syndrome (agenesis of the parathyroid and thymus) is an anomaly which involves the caudad branchial arches and pouches. with permission. and the recurrent laryngeal nerve. Do the parathyroid glands arise from the neural crest. http://web. meaning they belong to the APUD system? Maybe. Neck The migratory pathways of the parathyroid glands. Akin JT Jr. Congenital Anomalies Abnormal parathyroid development includes variations in location.207 demonstrated that the abnormal parathyroid tissue of normocalcemic primary hyperparathyroidism is characterized by morphologic and functional derangements.. but also may contribute to successful surgery. Parathyroid cysts may be congenital.) The following points are important to consider: Is the genesis of the parathyroid glands of ectodermal origin. weight. number. These are consistently seen in patients with primary hyperparathyroidism and hypercalcemia. and color. and presents with approximately 38 combinations. Figure 1-85 illustrates the anatomic locations of ectopic parathyroid glands found in a study by Shen et al. Casas et al.208 The procedure for locating such glands is presented in "Strategy for Finding Parathyroid Glands" later in this chapter.210 and Martin et al.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. and therefore from pharyngeal clefts 3 and 4? Maybe. This not only may reduce operative time. Skandalakis JE.htm 81/125 . parathyroid. usually at the levels indicated by the horizontal arrows. size.uni-plovdiv.209 Malhotra et al.

Among Hooghe's patients. If the inferior gland is not found. MRI. 76. Few intrathyroid parathyroid glands are discovered in the absence of disease. Table 1-10 shows the location of these glands.uni-plovdiv. Although CT. In the absence of an inferior thyroid artery. Wang139 stated that the vascular pedicle could be used to locate a low-lying parathyroid IV (Fig. Purcell et al. Krausz et al. or one of them may even follow a blood vessel deep into a sulcus of the thyroid. 19% of the organs were found in ectopic locations.1% on the right side. Despite the fact that Bonjer and colleagues concluded that the MIBI probe did not improve the outcome of parathyroid surgery in their study. Rowe JS Jr. (Modified from Shen W. Neck Anatomic locations of ectopic parathyroid glands. Read an Editorial Comment Pre-operative localization of parathyroid adenomas is even more difficult when thyroid nodules are present. Indeed. 1983. The frequency of such occult glands is not known. The superior parathyroid glands will probably lie about one inch above it.218 reported that in 416 parathyroidectomies.219 McHenry et al. and the inferior parathyroid glands will probably lie one-half inch below it. Parathyroid tissue within the thymus with primary hyperthyroidism was reported by Wei et al. along the esophagus. with permission. but it is fairly common to have more or fewer.htm 82/125 . Bonjer et al. scintigraphy with technetium-99m-sestamibi is an effective diagnostic tool.216 reported an intrathyroidal parathyroid gland in 7 percent of the cases and they advise ultrasonography for selection of patients for thyroid resection. Morita E. such a pair can be differentiated from a bilobate gland by the presence of a cleavage plane between them. both the superior and inferior parathyroid glands were supplied by the superior thyroid artery in the majority of cases225 (Fig.217 tabulated the adult position of 200 parathyroid glands in 50 cadavers.222 have reported a high degree of success using a combination of high-resolution ultrasound and technetium Tc99 sestamibi scanning to locate the parathyroids before surgery in patients with hyperparathyroidism.220 studied parathyroid localization with technetium-99m-sestamibi. or in the upper anterior mediastinum within thymic remnants. 1-87).139 Hooghe et al.224 advise that in the absence of thyroid pathology.213. the surgeon should start at the point at which the inferior thyroid artery enters the thyroid gland. Table 1-11). When fewer than four glands are found.) SURGICAL ANATOMY General Topographic Anatomy The parathyroid glands are usually found on the posterior surface of the thyroid gland. Higgins C. New York: McGraw-Hill. After a study of 160 autopsy specimens. all of which could be considered "normal. Gray SW. Gray et al.223 found in a retrospective study of 659 patients with sporadic primary hyperparathyroidism that the incidence of parathyrodid adenoma in two enlarged parathyroid glands was approximately 12%.8% on the left." Table 1-10. with permission. Clark OH. with number found in each location (n=54). Libutti et al. high-resolution ultrasonography should be the first step for localization of a parathyroid adenoma prior to surgery. http://web. the possibility of ectopic glands is hard to rule out. 5% had supernumerary parathyroids. It was observed that both the superior and inferior parathyroids are usually supplied by the inferior thyroid artery: 86. Vascular Supply Alveryd225 studied parathyroid arterial supply in 354 autopsy specimens. Typically there are four parathyroid glands.214 McIntyre et al. They reported that in patients with primary hyperparathyroidism alone. such as distant to the thyroid lobes. 1-86. Location of Parathyroids in 50 Cadavers Location on Thyroid Gland Superior Parathyroids. Anatomical Complications in General Surgery. each with its own capsule of connective tissue.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.221 explored the possibility of using 2-methoxyisobutylisonitrile (MIBI) labeled with technetium-99m scanning as a preoperative and intraoperative technique using a hand-held gamma probe. The same authors reported that the test's lack of sensitivity for the detection of multiglandular disease precludes its use for bilateral routine exploration in patients with hyperparathyroidism. the search continues for better imaging modalities. Düren M. Arch Surg 131:861-869. Duh QY.139 In practice. although glands have been found as high as the bifurcation of the carotid artery and as low as the mediastinum. and reported that the sensitivity and positive predictive value of this scintigraphic technique is comparable to or better than other localization procedures. we agree with the invited commentary of Linos221 that there is room for improvement of this technique and that the probe should continue to be used. Extreme locations are very rare. and technetium-99m/thallium-201 have been used for identifying the glands' primary hyperparathyroidism. Farr and associates212 found 10 examples among 100 patients with parathyroid tumors.215 reported that 18 of 309 patients (6%) who had undergone parathyroidectomy had intrathyroidal parathyroid glands. Reoperation for persistent or recurrent primary hyperparathyroidism. Siperstein AE. Several techniques have been developed for locating occult parathyroid glands. Read an Editorial Comment Szabo et al.5/24/2014 Print: Chapter 1. Scintigraphy and ultrasonography are needed when the patient has thyroid abnormalities in addition to hyperparathyroidism. % Inferior Parathyroids. it is more likely to be lower than higher. They are occasionally included in the thyroid capsule. % Upper third 8 2 Middle third 80 12 Lower third or below inferior pole 12 86 100 100 Source: Skandalakis JE. Two parathyroid glands can be fused to one another.

3 15.6 9.5/24/2014 139 Wang Print: Chapter 1. Neck stated that the vascular pedicle could be used to locate a low-lying parathyroid IV (Fig. trachea.8 20. with permission.9 Superior thyroid artery 8. Parathyroid gland in thyroid surgery.6 0.htm 83/125 . Table 1-11. 1-87). 1983.8 96. Gray SW. Rowe JS Jr. http://web. The figures indicate the frequency in percent of total number of cases. Fig. New York: McGraw-Hill.0 2.4 98.6 0. Source: Skandalakis JE.6 0.6 Artery from larynx.0 a From b Alveryd A.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.8 Thyroid ima artery 0. Variations in Vascular Supply of 1405 Parathyroids Identified at 354 Autopsiesa.4 c 86.8 17.7 2. or mediastinum 1.7 0. 1-86. cIncludes 10 cases (right side) and 13 cases (left side) in which only one gland was identified.389 (suppl):1-120.uni-plovdiv.1 c 76. esophagus. Anatomical Complications in General Surgery. Acta Chir Scand 1968.7 1.0 2.b Right Side Left Side 1 Parathyroid 2-3 Parathyroids Total 1 Parathyroid 2-3 Parathyroids Total Inferior thyroid artery 12.

bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. increased parathyroid hormone secretion remained unchanged.htm 84/125 .3% . They reported that.5/24/2014 Print: Chapter 1.226 found that the blood supply to the parathyroids seems to originate as follows: Superior parathyroids: 77. The schematic drawings show a lateral view of the larynx and trachea with the thyroid mobilized and dislocated ventrally and medially. with permission.) Fig. A to C. Neck A. with permission. Anatomic distribution of 312 upper parathyroid glands (parathyroid IV). but in these the location of the parathyroid is not shown. Innervation The innervation of the parathyroid glands is either direct from the superior or middle cervical ganglia. B. despite devascularization.Inferior thyroid artery 15. Nobori et al. Anatomic distribution of 312 lower parathyroid glands (parathyroid III).Anastomosis of inferior and superior thyroid arteries Inferior parathyroids: 90. The right and left parathyroids are indicated separately in each case. Dotted horizontal lines indicate the levels of the entrance of the uppermost and lowermost branches of the inferior artery in the thyroid parenchyma. The hatched areas indicate the location of the parathyroids. A to D.1% . or through a plexus in the fascia on the posterior lobar aspects.183:271. The greater frequency of supply by the superior thyroid artery seen in the work of Nobori et al. the cases without an inferior thyroid artery are also registered in separate drawings.Inferior thyroid artery Ander et al.227 studied the blood supply and parathyroid hormone secretion in patients with parathyroid adenoma or secondary hyperplasia. A. For the sake of completeness. Acta Chir Scand (suppl) 1968. Schematic drawings showing the positions of the parathyroid glands and their vascular supply in 12 cases with 5 parathyroids without adenoma. B. The anatomic basis of parathyroid surgery.uni-plovdiv.389:1-120. (Modified from Wang C.3% .) As noted previously. Variations in the location of the parathyroid glands in relation to the inferior artery on both sides in 354 cases with 2-5 glands. http://web. Delattre et al. Parathyroid gland in thyroid surgery. 1-87. Ann Surg 1976. in contrast to that of others could be attributable to the techniques used or perhaps to genetic differences in anatomy.109 found that a branch from the superior thyroid artery that anastomosed with the inferior thyroid artery supplied the superior parathyroid gland in approximately 45% of cases. (Modified from Alveryd A.

Explore the retroesophageal and retropharyngeal spaces.236 The order of these steps.228 which suggests that the PTH content of parathyroid tissue may be of use in differentiating normal from abnormal organs. The following steps are essentially those suggested by Adams.htm 85/125 . Step 6. Surgical Applications Preoperative localization of the parathyroid glands is a tremendous help for both patient and surgeon. especially steps 5 and 6. is controversial. General surgeons must take specific steps to find the glands. of course. but these cysts have never been found to be malignant.241 stated that after localization of the parathyroid adenoma a unilateral neck exploration produces results similar to bilateral exploration. but disappear after the removal of the cyst. too little stimulates secretion. Safran recommended aspiration of these cysts. parathormone (PTH). humoral hypercalcemia of malignancy (tumor hormone secretion into the systemic circulation distant to the skeleton with subsequent bone resorption) can be produced by parathyroid hormone-related protein (PTHrP). with special attention to the thymus or its remnant behind the manubrium. We quote from Perez and Pazianos230: [T]he absence of an elevated PTH level in the presence of hypercalcemia should exclude primary hyperparathyroidism as the cause.. whereas retinoblastoma protein immunoreactivity has not proven useful in distinguishing between benign and malignant parathyroid tumors. however. This should be done only after the pathology report on thymus and thyroid tissue has been received and no parathyroid tissue is reported. Explore the region above the upper pole of the thyroid gland as far as the hyoid bone." SURGERY OF THE PARATHYROIDS The most common indication for parathyroid surgery is hyperparathyroidism.232 this review stated that Mitmaker reported only 162 cases of parathyroid cysts in the literature in 1991.242 reported a very unusual case of a patient with hyperparathyroidism who experienced spontaneous left recurrent laryngeal nerve paralysis after http://web. Traynor et al. We strongly advise the interested student of the parathyroids to read the excellent paper of Weber et al. retract the lobe medially and anteriorly... In a series of 400 operations reported by Nathaniels and colleagues.234 Cady. we agree with LiVolsi231 who stated that "our understanding of parathyroid pathophysiology is far from complete.235 McGarity and Bostwick. Read an Editorial Comment Malignancy of the parathyroids is. However. Explore the superior surface of the thyroid gland. the mediator involved in the parathyroid glands of these subjects is unknown.5/24/2014 Print: Chapter 1. 19 required mediastinotomy. To the best of our knowledge. rare but may involve one or more parathyroids. Step 2. Dissect the superior mediastinum as far as possible. Ligate the middle thyroid veins.the PTH level. Angelos et al. Gupta et al. and expose the recurrent laryngeal nerve. Strategy for Finding Parathyroid Glands The normal location of the superior and inferior parathyroid glands has been described. Step 5. Too much serum calcium inhibits production of PTH. Perform subtotal thyroidectomy. and 17 were in the posterior mediastinum. which present as masses at the lateral or lower neck. a feedback system is formed between the circulating calcium and the secretion of PTH..uni-plovdiv. with a lower incidence of functioning cysts. and requires less operative time.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.240 stated that Ki-67 (cell-cycle associated antigen) may give valuable information as to the malignant potential of parathyroid tumors. A case of a functioning parathyroid cyst was presented by Safran. Farnebo et al. is possible without significant operative delay. Hypercalcemia. To maintain normal calcium in the blood. Neck aspects. HISTOLOGY AND PHYSIOLOGY The major portion of the parathyroid parenchyma is formed by the principal cells and a minor part is formed by oxyphilic cells.238 there were 84 mediastinal parathyroid tumors.236 and Edis:237 Step 1. and in the regulation of calcium and phosphate metabolism. Perhaps all the parathyroid cells participate in the secretion of the parathyroid hormone. is considered too high for nonparathyroid hormone-mediated cause of hypercalcemia other than primary hyperparathyroidism. Cisneros et al. Rarely. Of these. Very rarely parathyroid cysts are associated with hyperparathyroidism. Step 3.239 advise that preoperative 99m-technetium sestamibi (MIBI) localization of simple parathyroid adenoma with hyperparathyroidisms will reduce not only operative time but also the extent of surgical dissection and risk. We believe mediastinal exploration should be the procedure of last resort.229 stated that in patients with nonmetastatic squamous cell carcinoma of the skin. Sixty-seven were in the anterior mediastinum. although in the normal range. Surgeons should decide in the operating room how radical a procedure they will use and whether removal of adjacent anatomic entities is necessary.233 found that rapid uptake of methylene blue by the parathyroid glands suggests that selective intraoperative use when glands are difficult to locate intraoperatively. As suggested by the authors of this study. hypophosphatemia. because they cannot explore the entire neck. and elevated serum parathormone are always present. Step 4. The remainder were removed through a neck incision. Ryan et al. Further explore the mediastinum at a second operation. remains to be defined. rather than a routine preoperative infusion. information from molecular biology studies of calcium-sensing receptors and the genes regulating calcium sensitivity in parathyroid tissue (both normal and abnormal).

Table 1-12.354 Reoperation without localization prior to surgery 60% Satava et al." Miccoli et al. Barry et al.243 reported the ninth case of spontaneous infarction of a parathyroid adenoma in primary hyperparathyroidism. Richards et al.352 Martin et al. low morbidity. Caccitolo et al. Angelos 251 studied patients with primary hyperparathyroidism who were evaluated by preoperative scintigraphy. However.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck..254 stated that total parathyroidectomy with autotransplantation in 19 patients with severe secondary (renal) parathyroidism relieves the hyperthyroidism symptoms.256 believe that the correction of postexploration hypocalcemia using cryopreservation and autotransplantation is sound in theory.259 reported that recurrent hyperparathyroidism eventually develops in most patients with multiple endocrine neoplasia type I (MEN I).257 stresses the importance of marking the site of parathyroid transplantation. Chen et al. D'Avanzo et al. Angelos concluded.247 stated that patients with primary hyperparathyroidism and multiple gland enlargement may be treated by conservative surgery. Proye et al. with the most marked improvement occurring within the first 10 days after surgery. Kikumori et al.252 recommended endoscopic parathyroidectomy after preoperative localization of parathyroid lesions and intraoperative parathyroid hormone assay. short length of stay.uni-plovdiv.260 reported that grafting of the parathyroids with total thyroidectomy is successful and that the glands fuction for a long time.258 removed a parathyroid adenoma which was located in the piriform recess.245 used the term "parathymic" to designate an undescended parathyroid gland that is located high in the neck just below or above the carotid bifurcation. Rates of successful surgery for primary hyperparathyroidism are shown in Table 1-12.htm 86/125 .353 Granberg et al.248 reported that parathyroidectomy in elderly patients (over 70 years) can be performed with high cures. For the treatment of familial hyperparathyroidism. Using endoscopic laser technology. Burgess et al. Ryan and Lee 250 emphasized the effectiveness and safety of 100 consecutive parathyroidectomies in normalizing serum calcium. since the inferior parathyroids and the thymus arise from the third pharyngeal pouch. "Although radioguided parathyroid surgery is an effective surgical approach.[s]tandard four gland exploration will continue to be needed for many patients.244 Billingsley et al. Successful Surgery for Primary Hyperparathyroidism Procedure Success Rate Investigator Initial operation 95% Clark et al. while those with negative scans had successful standard parathyroidectomies. They had good results in 39 patients. Although long periods of remission are possible after subtotal parathyroidectomy. Since hyperparathyroidism may develop after autotransplantation of histologically normal parathyroid tissue. Thrombosis of the parathyroid blood supply was reported by Dowlatabadi. the remaining patients with positive scans underwent successful radioguided operations. The above authors speculate that perhaps the infarction is secondary to the tumor outgrowing its blood supply. Starr et al. Stojadinovic et al.. or after a period of postsurgical hypoparathyroidism. Mollerup and Lindewald 255 stated that primary hyperparathyroidism and renal stone disease are common. but a number of patients experience recurrence of their stone disease in the presence of normal calcium rates after successful parathyroidectomy.351 Edis et al. Pasieka and Parsons 249 reported that parathyroidectomy reduces preoperative symptomatology in patients with primary hyperparathyroidism. but did not improve the rate of normalization of serum calcium. resecting only the grossly enlarged glands and not biopsying the normal looking glands. Neck Angelos et al. but difficult in practice. After removal of a parathyroid adenoma with abscess formation the vocal cord function returned. no mortality.253 reported that intraoperative measurement of intact parathyroid hormone to measure adequacy of resection of hyperfunctioning tissue during parathyroidectomy decreased the harvesting of frozen sections. Embryologically the term is correct.242 reported a very unusual case of a patient with hyperparathyroidism who experienced spontaneous left recurrent laryngeal nerve paralysis after which his hypercalcemia resolved.355 http://web. and high patient satisfaction. Zaraca et al. The anatomy of the infarction is enigmatic. After excluding several patients based on their histories. the term will confuse the surgeon who is not familiar with the ontogenic location of the parathyroid glands and who may think it refers to a "thymic" location of the parathyroid.5/24/2014 Print: Chapter 1. and the recurrence rate of hyperparathyroidism is low.246 advised subtotal parathyroidectomy and routine transcervical thymectomy.

this artery arose from the superior thyroid artery. Its repair does not fall into the field of the general surgeon. 1-26). while the proximal end and the foregut grow cephalad. attaching to the perichondrium of the end of the cartilage. A subcutaneous tough band covering the laryngeal mucosa extends from the cricoid cartilage to the thyroid cartilage and to the vocal processes of the arytenoid cartilages.262 Failure to find an adenomatous gland in the presence of hyperparathyroidism is evidence of an inadequate procedure. and fibroelastic tissue completing the arches posteriorly. At first the tracheal bifurcation is high in the cervical region. The same authors cautioned that routine autotransplantation was associated with a high incidence of postsurgical hypocalcemia. Intraopertive parathyroid hormone assay may prove to be an important adjunct in this population of patients who have unsuspected multigland disease. In cricothyroidostomy the severed cricothyroid artery.208 advised bilateral cervical exploration and preoperative localization. The cartilages are about 4 mm high and about 1 mm thick. the site of emergency cricothyroidostomy. In some cases the cartilages of two or more rings fuse.uni-plovdiv. To avoid repeated parathyroidectomies.265 Berger et al. the lung buds appear at the tip of the tracheal primordium. It is covered anteriorly by the investing layer of the deep cervical fascia and posteriorly by the pretracheal fascia (see Fig. 1-88. Vascular compression of the trachea was reported by Burch et al.356 NOTE: According to Cheung et al. smooth muscle fibers. Cartilage appears in the trachea and primary bronchi in the tenth week. The authors also identified several veins crossing the membrane. This is the cricothyroid membrane or ligament. The trachea begins at the level of the sixth cervical vertebra.267. may bleed unseen directly into the trachea.htm 87/125 . At the end of the third week of gestation.357 and Sugg et al. 1-88). is therefore flat. Fig. contraction of the muscle narrows the lumen of the trachea. Hellström and Ivemark263 reported failure to find the diseased gland in 10 percent of 92 patients. and is quite small in early childhood. Remember: the respiratory diverticulum appears at the ventral wall of the foregut.. which is similar to that found in multiple endocrine neoplasia type I. In some cases the ends of the cartilage may bifurcate.269 SURGICAL ANATOMY General Structure The trachea. The diameter of the trachea is greater in men than in women. In this way. They stated that in 93 percent of individuals. Its bifurcation is at the level of the sixth thoracic vertebra in the erect position.270 who emphasized the importance of knowledge of the pathway of the cricothyroid artery (Fig. The smooth muscle fibers are arranged horizontally. ANATOMIC COMPLICATIONS OF PARATHYROIDECTOMY The complications of parathyroidectomy are the same as those associated with thyroidectomy (previously considered in this chapter) and radical neck surgery (to follow later in this chapter).bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Lo and Lam264 advised immediate autotransplantation of parathyroid glands to avoid hypoparathyroidism. or anastomosing branches. at birth it will be at the level of the 4th or 5th thoracic vertebra. together with the esophagus and thyroid gland. Their findings on the dimensions of the cricothyroid membrane are seen in Figure 1-89. The highest of the tracheal rings is attached to the cricoid cartilage by the cricotracheal membrane. The cervical part of the trachea consists of 4 or 5 incomplete rings of cartilage and their connecting membranes. with possible aspiration and death. it crossed the upper one-half of the cricothyroid membrane in 14 out of 15 cadavers. This is the widest of the tracheal cartilages. The trachea (anterior) and the esophagus (posterior) become separated caudally. the foregut is divided in two portions: ventral. There are 16 to 20 tracheal cartilages. Neck 355 Reoperation with localization prior to surgery by noninvasive techniques 89% Satava et al. which is responsible for the genesis of the respiratory system. formed by the fibromuscular membrane. Tracheoesophageal fistula is the only defect frequently encountered. This heterogeneity may result in failure to recognize multigland disease if a unilateral neck exploration is performed. lies in the visceral compartment of the neck.5/24/2014 Print: Chapter 1. and glands appear a week later. or the fourth to fifth thoracic vertebrae when supine. Shen et al.268 Congenital Anomalies The trachea is rarely subject to anomalies. TRACHEA AT THE NECK EMBRYOGENESIS Normal Development There is confusion in the literature regarding the use of the terms ventral and dorsal wall of the foregut. The distal end of the groove grows caudad. The surgical anatomy of the cricothyroid membrane was studied by Dover et al. Grant et al. in the fourth week.358 invasive techniques such as arteriography and selective venous sampling fail to localize the abnormal parathyroid gland. but by separation later and the formation of the esophagopharingeal border. the laryngotracheal groove appears on the ventral surface of the upper end of the embryonic foregut. The anterior wall of the compartment is composed of sternothyroid and sternohyoid muscles.261. which is responsible for the genesis of the esophagus. usually only partially. and dorsal. http://web.266 stated the following: There is a marked heterogeneity in gland size in patients with sporadic multigland hyperplasia. The posterior surface of the trachea..

The dimensions and vascular anatomy of the cricothyroid membrane: relevance to emergent surgical airway access. Howdieshell TR.5/24/2014 Print: Chapter 1. http://web. (Modified from Dover K. Colborn GL. 1-89. Neck Cricothyroid artery (arrow) traversing upper portion of cricothyroid membrane.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.9:291-295. with permission.htm 88/125 .) Fig. Clin Anat 1996.uni-plovdiv.

The isthmus of the thyroid gland commonly lies at the level of the second and third tracheal rings. Range and (mean) values reported in millimeters. The two veins may form a common trunk entering the superior vena cava or the left brachiocephalic vein. In about 10 percent of individuals. They are retracted laterally. see chapter on esophagus). these descending branches anastomose with ascending branches of the bronchial arteries. http://web. Neck Dimensions of cricothyroid membrane. The isthmus can be retracted superiorly or divided between hemostats. 1-58). Beneath the skin. The dimensions and vascular anatomy of the cricothyroid membrane: relevance to emergent surgical airway access. it can be ligated and incised. or following severe facial trauma.) Vascular Supply Arteries The chief sources of arterial blood to the trachea are the inferior thyroid arteries. Veins Small tracheal veins join the laryngeal vein or empty directly into the left inferior thyroid vein. The isthmus can be retracted upward or downward to reach the trachea. or as a concurrent procedure when a total laryngectomy is performed.9:291-295. These muscles lie between the investing layer and the pretracheal fascia on either side of the midline. SURGERY OF THE TRACHEA The following are the most common procedures performed on the trachea: Tracheostomy Resection of malignant tumors (primary or secondary) or benign tumors Associated benign or malignant tracheal compression for tumors close to the trachea-related anatomic entities Treatment of tracheal stenosis Treatment of tracheoesophageal fistulas (multiple procedures. laryngeal edema or postoperative vocal cord paralysis. It may also be performed as an emergency procedure to establish an airway when there is obstruction by a foreign body. although the lower approach is usually preferable. Lymphatics The pretracheal and paratracheal lymph nodes receive the lymphatic vessels from the trachea. less frequently more caudal. At the tracheal bifurcation. it is frequently more cranial. Innervation The trachealis muscle and the tracheal mucosa receive fibers from the vagus nerve. Several structures are encountered. recurrent laryngeal nerves. Indications for Tracheostomy Tracheostomy is performed following extensive operative procedures upon the neck when postoperative laryngeal edema exists. A suspensory ligament of the thyroid (see "Deep Fascia: Pretracheal Layer" describing the fasciae of the neck previously in this chapter) and a levator thyroid muscle may also be present in. and sympathetic trunks. HISTOLOGY AND PHYSIOLOGY The histology and physiology of the trachea is covered briefly in the chapter on the respiratory system. It can be performed either above or below the isthmus of the thyroid gland. There are several structures within the visceral compartment under the pretracheal fascia. Anatomic Landmarks and Relations The usual site of a tracheostomy is between the 2nd and 4th or 3rd and 5th tracheal rings. The inferior thyroid veins arise as a venous plexus on the anterior surface of the isthmus of the thyroid gland. Clin Anat 1996. they may be united by a jugular venous arch at the level of the seventh to eighth tracheal rings in the suprasternal space of Burns. Deep to the investing fascia are the sternohyoid and sternothyroid muscles. Colborn GL. the platysma lies in the superficial fascia and is absent in the midline.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Small autonomic ganglia are numerous in the tracheal wall.5/24/2014 Print: Chapter 1. The anterior jugular veins may lie close to the midline. the two lobes of the thyroid are not connected by an isthmus. the midline. (Modified from Dover K. with permission. or close to. Howdieshell TR. if necessary. Left and right descending veins enter the respective brachiocephalic veins (see Fig.uni-plovdiv. The possibility of a thyroid ima artery should not be forgotten. more importantly.htm 89/125 . The investing layer of deep cervical fascia is encountered when the superficial fascia is reflected.

272 performed mediastinal tracheostomies in 12 patients with advanced carcinoma of the lower neck and superior mediastinum. The left common carotid artery may arise from the brachiocephalic trunk. The inferior thyroid vein is often asymmetric.279 The anterior jugular veins may be encountered as the investing fascia is incised. usually.. Read an Editorial Comment Remember The brachiocephalic artery in adults lies anterolaterally to the right of the trachea and very close to the tracheal stoma.4%) who underwent operating room tracheostomy. Neck thyroid gland. the majority of surgeons take a window out of the 2nd or 3rd ring. then dilated. 1-90). it should be brought out through a stab wound on the opposite side of the neck. it is located behind the sternum at the upper half of the manubrium. When emergency tracheostomy is indicated. the vein is located at the lowest part of the neck. The procedure is very simple. After evaluating tracheostomy in 76 pediatric burn patients (newborn to three years of age).uni-plovdiv. resulting in a tracheoarterial fistula. The tracheostomy tube is inserted. 4th.276 Know the location of the left brachiocephalic vein. Today. although the lower approach is usually preferable. In adults. The common carotid artery can be injured when attempting a tracheostomy in the newborn.277 Upadhyay et al. The incision in the trachea can be performed either in vertical or horizontal fashion. the skin and subcutaneous tissue are incised by a short vertical incision. After laryngeal stabilization. A hook is usually placed beneath the cricoid cartilage in the midline to stabilize the trachea and pull it forward. The artery can be eroded by a tracheostomy tube. The anatomic landmark is the 1st tracheal ring. If a drain is used. Combined injuries of the trachea and esophagus should be repaired primarily. the procedure of choice is cricothyroidostomy. In children. Maipang et al.274 Yang et al. They should be ligated to avoid bleeding. Vascular Injury The following alerts you to several vessels that may bleed during tracheostomy. Division of the thyroid isthmus is a good technique for avoiding complications. The brachiocephalic artery and left brachiocephalic vein can be injured if sharp dissection is carried too far downward. The inferior thyroid veins drain inferiorly into the brachiocephalic veins. either forming a single stem or draining separately.5/24/2014 Print: Chapter 1. Neonates and infants have more complications.htm 90/125 .7%) who underwent bedside tracheostomy and the 159 patients (9. It is important to select a tube of the proper size so that pressure of the tube will not cause necrosis of the posterior tracheal wall.271 concluded that pediatric tracheostomy may be performed safely without complications and with acceptable chronic morbidity. just above the manubrium. The same authors described the complications that occur when tracheostomy is performed above or below the isthmus. The branches of the superior and inferior thyroid arteries may anastomose across the midline. lower tracheostomy can also produce a galaxy of anatomic complications in adults and children. Fatal bleeding from injury was reported by Silen and Spieker. The sternocleidomastoid muscle can be used between the two repaired organs. The isthmus can be retracted superiorly or divided between hemostats. Fig. the 3rd. The subclavian artery and vein can be compromised by a tracheostomy tube that is incorrectly curved or placed too low (Fig. and 5th tracheal rings are divided vertically from above downward.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. http://web. The incision is held open for insertion of the tracheostomy tube. The venous thyroid plexus over the thyroid gland drains into the thyroid veins. The space between the isthmus and the suprasternal notch is at the level of the 2nd or 3rd tracheal rings above and the 4th or 5th tracheal rings below. more liable to injury. however. Moreover. Of course. Their study of 470 patients showed no significant difference in complications between the 311 patients (8. 1-90. it has been mistaken for the trachea. hence. High tracheostomy can produce tracheal stenosis. The membrane is palpated and incised transversely. thereafter crossing the lower part of the cervical trachea. this depends upon the thickness and width of the isthmus. A thyroid ima artery is very occasionally present. ANATOMIC COMPLICATIONS Tracheostomy General Precautions Ger and Evans273 related the anatomic complications of tracheostomy to the age of the patient and the location of the stoma. Inferior thyroid veins and the thyroid ima artery are located at the anterior wall of the trachea.278 reported that tracheostomy can safely be performed without transporting the patient to the operating room. and must be ligated if found. Coln et al.275 and Takano. which is identified below the lower border of the cricoid cartilage and above the upper border of the isthmus.

Tube placed too low.) Organ Injury ESOPHAGUS Injury to the esophagus usually occurs not from errors of perception of the anatomy.uni-plovdiv.5/24/2014 Print: Chapter 1. New York: McGraw-Hill. B. POSTTRACHEOSTOMY SWALLOWING DYSFUNCTION The adverse effect of a cuffed tracheostomy tube on the swallowing mechanism was studied by Bonanno. RECURRENT LARYNGEAL NERVES Injury to these nerves can occur during tracheostomy as well as during thyroidectomy (see "Anatomic Complications of Thyroidectomy"). and external laryngeal nerves revealed that nerve injury was not a factor. with permission. Bonanno concluded that the dysfunction was produced by inhibition of elevation and anterior rotation of the larynx and by failure of the hypopharyngeal sphincter to open completely. glossopharyngeal. Anatomical Complications in General Surgery.htm 91/125 . Rowe JS Jr. C. Gray SW. but from errors in the use of the tracheostomy tube.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. and sublingual) are shown in Fig. 1-90). The tracheal wall may be eroded and the subclavian artery may be occluded. http://web. Neck Tracheostomy tubes: A. It is possible. 1983. Subclavian vessel may be occluded. Tube with correct curvature correctly placed. however. Placement of the tube through the thyrohyoid membrane can also produce vocal cord injury. 1-91.280 PNEUMOTHORAX AND PNEUMOMEDIASTINUM Pneumothorax and pneumomediastinum also have been reported. Tube too curved. Cricothyroidostomy The anatomic complications of cricothyroidostomy are as follows: Bleeding Pneumomediastinum Subcutaneous emphysema Change of voice Paresis of the vocal fold Laryngeal fracture Dysphonia Subglottic stenosis SALIVARY GLANDS INTRODUCTION The major salivary glands (parotid.279 The stoma should be formed below the first ring. submandibular. Inadequate Procedures An appreciation of the angle of the trachea to the surface of the neck is important in selecting a tube with the proper curvature. recurrent. The distal end of a tube with too much curvature will erode the anterior tracheal wall.281 Evaluation of the maxillary. LARYNX Too high a tracheostomy can result in direct injury to the vocal cords. (Modified from Skandalakis JE. to create an iatrogenic tracheoesophageal fistula by careless manipulation.185 Roe282 recommended a 60-degree curvature (Fig.

into which the small ducts of the accessory tissue empty.2 reported an unusual salivary gland choristoma in the middle ear space which appeared to be a developmental abnormality associated with abnormalities of adjacent structures. Fig. Martinez Subias et al.5/24/2014 Print: Chapter 1. and occasionally forms even more medially on the buccinator muscle.) Salivary choristomas. investing the facial nerve (VII) with its branches. and displaced surface glands within alveolar bone may develop into intraosseous salivary neoplasms. (Modified from Anson BJ (ed). These accessory parotid tissues have their own blood supply from the transverse facial artery. It grows posteriorly. hamartomas.283 Ha et al.htm 92/125 . Deep lateral view of the lingual region with the body and part of the ramus of the mandible cut away to expose the glands and related structures. Salivary glands and their ducts. New York: McGraw-Hill. toward the ear.285 reported total agenesis of the parotid gland. 1-91. 1966. Congenital Anomalies Congenital absence of major salivary glands is rare. and parotid glands. submandibular. We agree with Anson and McVay286 that accessory tissue is common (20%). Most common is a local aggregation of glandular tissue (the "socia parotis") along the parotid duct. Neck The major salivary glands (parotid. SURGICAL ANATOMY General Relations http://web.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. and sublingual) are shown in Fig. Dissection showing the sublingual. Accessory glandular tissue separated from the main gland is not rare. Parotid Glands EMBRYOGENESIS Normal Development Early in the sixth week of development. Morris' Human Anatomy (12th ed). embryonic rests. Parotid tissue may extend forward between the two pterygoid muscles ("pterygoid lobe") and upon the masseter muscle ("accessory lobe"). The solid cords subsequently become canalized. with permission. 1-91. and the cells at the tips of the branches differentiate into secretory acini. the parotid duct appears as a solid outgrowth of the oral epithelium. submandibular (submaxillary).uni-plovdiv.

77 described three surfaces (lateral. the stylomandibular ligament between the styloid process and the angle of the mandible is derived from the deep layer. It turns medial at the anterior margin of the muscle. The anatomic relations of the buccal pad of fat. the surgeon should be familiar with all of them. and pharyngeal wall From the anterolateral edge of the gland. the branches of the facial nerve are "intimately enmeshed within the gland tissue. The buccal pad of fat: a review. and posterior belly of the digastric muscle Lateral: Investing layer of the deep cervical fascia. It is contained within the investing layer of the deep fascia of the neck. and medial pterygoid muscle Posterior: Mastoid process. the small pterygomandibular space and the space of the body of the mandible. skin. and separates the parotid from the submandibular gland. 1-92). which is thin and weak. and superior). A short accessory duct may enter the main duct. sternocleidomastoid muscle. The superficial layer is dense and tough in comparison to the deep. anterior. Accessory parotid tissue may extend along the parotid duct. Ellis H. Neck The parotid gland lies beneath the skin. illustrate the problem. The parotid space communicates medially with the lateral pharyngeal space and with the posterior area of the masticator space.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. with permission. Two important studies. Winsten and Ward289 visualized the gland as essentially unilobar. There has long been controversy about the lobes of the parotid gland.uni-plovdiv. and two extremities (superior or base. (Modified from Tostevin PMJ. 1-92. the stylomandibular ligament. internal carotid artery. between the masseter and buccinator muscles. in front of and below the ear. Davis and coworkers288 concluded that there is a superficial lobe and a deep lobe of the gland." in relation to the facial nerve is a practical custom.286. The parotid gland occupies the parotid space. the parotid duct (Stensen's) passes lateral to the masseter muscle. Parotid Fascia The parotid fascia is the splitting of the general investing layer that envelops both the parotid and submandibular (submaxillary) glands.287 Fig. three borders (anterior. ramus of the mandible. and posterior belly of the digastric muscle and facial nerve Superior: External auditory meatus. styloid process. The buccal pad is located medial to the parotid duct. Beahrs23 agreed with the unilobar concept. which both appeared in 1956. the pterygoid muscles. especially those that must not be sacrificed. or two lobes (superficial and deep). We have seen one lobe. where it is related to the buccal fat pad or "boule de Bichat" (Fig. Since many intraparotid anatomic entities radiate from the gland. internal jugular vein. or "lobes. the boundaries of which are: Anterior: Masseter muscle. In contrast. Clin Anat 1995.5/24/2014 Print: Chapter 1.) Some authors41.290 stated that the surgical division of the parotid gland into 3 parts. and inferior or apex).8:403. Poncet et al. However. called the parotid fascia. medial. The posterior area of the masticator space contains the masseter muscle. It is tough.36 The view that one accepts does not change the surgical procedure of superficial parotidectomy.287 The buccinator muscle is pierced by the duct. forming the superficial and deep layers. We think that the so-called third or fourth lobes are nothing but embryologic parotid segments. as did Hollinshead." with no cleavage plane between the nerve and gland. Bed of the Parotid Gland Complete removal of the parotid gland reveals the following structures (the acronym VANS may be helpful in remembering them): One Vein: internal jugular http://web. and posterior). and platysma muscle Medial: Investing layer of the deep cervical fascia. the branches of the facial nerve run between them. and temporomandibular joint Inferior: Sternocleidomastoid muscle. It enters the oral cavity at the level of the upper second molar tooth. It is separated from the submandibular gland by a fascial thickening.htm 93/125 .

bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. which is above it. The glossopharyngeal nerve (IX) snakes around the stylopharyngeus muscle. spinal accessory (XI). New York: McGraw-Hill. 1-94) enters the superior surface of the parotid gland. hypoglossal (XII) Four anatomic entities starting with "S": styloid process. 1-93. It enters the cranial cavity through the foramen spinosum and supplies blood to the dura mater within the skull. with permission. Rowe JS Jr. spiraling around its posterior surface as it passes inferiorly and medially to the wall of the pharynx. neck. The vagus nerve (X) is located under or. the retromandibular vein divides. Vascular Supply Arteries The external carotid artery (Fig. Neck Two Arteries: external and internal carotid Four Nerves: glossopharyngeal (IX). occasionally. stylopharyngeus. and the stylohyoid.) NOTE: An artery which has nothing to do with the parotid is the middle meningeal artery: it is a branch of the maxillary artery which arises slightly anterior to the neck of the mandible in the infratemporal fossa. Gray SW. Still within the gland. The latter gives rise to the transverse facial artery. vagus (X). The spinal accessory nerve (XI) is superficial and lateral to the carotid sheath.uni-plovdiv. just lateral to the tonsillar fossa. In addition to the styloid process are the muscles beginning with "S": the styloglossus and stylopharyngeus. (Modified from Skandalakis JE. The posterior branch joins the posterior auricular vein to form the external jugular vein.5 cm long and its tip is located between the external and internal carotid arteries. The anterior http://web. The origin of the superior laryngeal branch is found in this vicinity. Occasionally the external carotid artery is embedded within the deep lobe. The hypoglossal nerve (XII) is located superficial and medial to the carotid sheath. 1983. The internal carotid artery can be found anterior to the internal jugular vein. Anatomical Complications in General Surgery. and styloglossus. Veins The superficial temporal vein (Fig.5/24/2014 Print: Chapter 1. 1-93) enters the inferior surface of the gland and divides at the level of the neck of the mandible into the maxillary and superficial temporal arteries. which are beneath the external carotid artery. or facial pain. between the internal jugular vein and the internal carotid artery. positioned posteriorly. and stylohyoid muscles. Each of these branches emerges separately from the superior or anterior surface of the parotid gland. An elongated styloid process (called Eagle's syndrome because Eagle described it in 1937) can cause throat. Fig.htm 94/125 . The topography of VANS is as follows: The internal jugular vein is located medial to the styloid process. but usually it is superficial. The styloid process in adults is approximately 2. It receives the maxillary vein to become the retromandibular vein. Diagrammatic representation of the relationship of the parotid gland to the branches of the external carotid artery.

where it enters into the formation of a nerve plexus on the promontory of the medial wall of the middle ear cavity. middle ear. Anatomical Complications in General Surgery. The presynaptic parasympathetic fibers of the lesser petrosal nerve synapse upon the neurons within the otic ganglion. 196). The otic ganglion is suspended from the mandibular nerve. New York: McGraw-Hill. Fig. carrying postsynaptic parasympathetic fibers to the glandular units. consisting of presynaptic parasympathetic neurons. and then descends through the foramen ovale to reach the otic ganglion. Innervation Autonomic Nervous System The parotid gland is innervated by the parasympathetic and sympathetic divisions of the autonomic nervous system. This plexus consists of a mixture of sensory (pain) and autonomic fibers. His opinion is that perhaps a significant number may be left in the skin flaps. thereby forming the common facial vein. Its tympanic branch (the nerve of Jacobson) ascends into the skull through a small tympanic canaliculus to reach the middle ear. 1983. These nodes. Neck Still within the gland. Several branches of the auriculotemporal nerve pass into the parotid. near the foramen spinosum. leaves the middle ear cavity. (Modified from Skandalakis JE. Diagrammatic representation of the relationship of the parotid gland to tributaries of the external and internal jugular veins. He reported finding 1 to 11 lymph nodes in 17 specimens of radical parotidectomy. and external auditory meatus. travels across the floor of the middle cranial fossa. upper face. emerges from this plexus. The anterior branch emerges from the gland to join with the facial vein. with permission.htm 95/125 . these fibers elicit profuse. which pass on either side of the middle meningeal artery. just inferior to the foramen ovale.uni-plovdiv. a tributary to the internal jugular. 1-95. Remember: the facial nerve is superficial. the artery is deep. Rowe JS Jr." Fig. and the retromandibular vein lies between them. 1-94. forming one of the two roots of the auriculotemporal nerve. and anterior pinna. Some of these fibers are delivered to the secretory units by branches of the facial nerve as it passes through the gland. http://web. nose. The lesser (superficial) petrosal nerve (Fig. The posterior branch joins the posterior auricular vein to form the external jugular vein. The postsynaptic parasympathetic fibers leave the ganglion. Parotid nodes within the gland drain the gland itself. when stimulated by sensory (or psychic) stimuli. Last 292 has a beautiful and pragmatic expression in which he stated that the secretomotor fibers reach the gland by "hitchhiking. send lymph to the subparotid nodes and eventually to the nodes of the internal jugular vein and spinal accessory chains (see Table 1-2). Gray SW. the retromandibular vein divides. palate. as well as the nasopharynx. Marks291 discussed the number of lymph nodes in the parotid area. watery secretion of the gland (Fig. The parasympathetic fibers are secretomotor. lateral portions of the eyelids.5/24/2014 Print: Chapter 1.) Lymphatics The preauricular lymph nodes in the superficial fascia drain the temporal area of the scalp. The parasympathetic innervation of the parotid gland originates from the glossopharyngeal nerve. 1-95).bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. in turn.

Fibers follow the vertebral roots of the three upper thoracic nerves. branches travel toward the external carotid artery forming a sympathetic plexus. reaching the superior cervical ganglion. 1989. Fig.5/24/2014 Print: Chapter 1. Fig. (Modified from Basmajian JV. Broken line. 1-97). Grant's Method of Anatomy [11th ed]. Solid line. 1-96. postganglionic pathway. http://web. The primary function of the sympathetic system may be vasoconstriction. Baltimore: Williams & Wilkins.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. 1-97. whose fibers follow the branches of the external carotid to reach the parotid gland. preganglionic pathway. with permission.htm 96/125 . Neck Schema of the parasympathetic innervation of the parotid gland.) The sympathetic supply to the parotid originates from spinal cord segments T1-T3 (Fig. then travel via white rami communicantes to the upper sympathetic thoracic trunk and upward to the cervical sympathetic. Secretomotor nerve to parotid gland.uni-plovdiv. Slonecker CE. From this.

deep to the main stem of the mandibular division of the trigeminal nerve. temporomandibular joint. carries postganglionic parasympathetic fibers to the parotid gland. the auriculotemporal nerve is sensory to the external ear and ear canal.htm 97/125 . white rami communicantes.5/24/2014 Print: Chapter 1. The preganglionic parasympathetic fibers for the parotid are carried initially by the glossopharyngeal nerve and its lesser petrosal branch. Fig. the postganglionics arise in the otic ganglion. In addition.uni-plovdiv. WRC. Auriculotemporal Nerve The auriculotemporal nerve. http://web. It traverses the upper part of the parotid gland and emerges with the superficial temporal blood vessels from the superior surface of the gland (Fig. 1-98.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Neck Sympathetic supply to the parotid gland. and skin of the temporal part of the face. just outside the skull. a branch of the mandibular division of the trigeminal cranial nerve. 1-98).

mandibular. The auriculotemporal nerve is. In most individuals. 1983.5/24/2014 Print: Chapter 1. but disappears after 4 to 6 months. but there is no true fascial plane between these portions. with permission.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Thereafter it passes obliquely upward and forward to the interval between the earlobe and the angle of the mandible. It reaches the posterior border of the sternocleidomastoid muscle near the junction of the upper third and lower two-thirds of the muscle (Erb's point). zygomatic. are the facial nerve and the great auricular nerve. based on a series of simple to complex arrangements. Other landmarks for locating the facial nerve have been suggested. Therefore. 1-98) enters the posterior surface of the parotid gland about 1 cm from its emergence from the skull through the stylomastoid foramen. Related Nerves Two nerves that are related to the parotid gland. the auriculotemporal nerve communicates with the facial nerve. but six major patterns of branching. FACIAL NERVE The facial nerve has nothing to do with parotid innervation.uni-plovdiv. New York: McGraw-Hill. the facial nerve's position makes it particularly vulnerable. and temporal branch of the facial nerve. about midway between the angle of the mandible and the cartilaginous ear canal. (Modified from Skandalakis JE. the facial nerve typically divides to form five branches: temporal.294. About 1 cm from its entrance into the gland. http://web. Numbness in the preauricular region. roughly following the course of the external jugular vein (Fig. and the lobe of the ear results from injury to this nerve. The main trunk of the facial nerve (Fig. Neck Diagrammatic representation of the relations of the parotid gland to the facial nerve and its branches. Beahrs23 suggested the following method to identify the facial nerve: The lower tip of the mastoid process is palpated and a fingertip is placed on the lateral surface pointing forward.288 In general. It is usually sacrificed at parotidectomy.5 cm above the labial tubercle of the upper lip Cervical branch: from notch to a point ("B") halfway between the ear lobe and the angle of the mandible Marginal mandibular: from notch to a point about 1 cm below the vascular notch of the mandible Fig. the branches of the facial nerve may be approximated by a radiating series of lines. buccal. an initial bifurcation called the pes anserinus forms an upper temporofacial and a lower cervicofacial division.. Usually the order of the structures from the tragus anteriorly is: the auriculotemporal nerve. It is important to remember that at birth the child has no mastoid process. 1-98).htm 98/125 . sensory and secretory. In summary. 1-99): Temporal branch: from notch to point "A" halfway between ear and lateral angle of the eye Zygomatic branch: from notch to lateral angle of eye Buccal branch: from notch to . but we present the nerve here because of its very close relationship with the parotid and salivary glands.295 GREAT AURICULAR NERVE The great auricular nerve arises from the second and third nerves of the cervical plexus. The easiest method of identification takes a lateral approach. the nerve and its branches lie in a plane dividing the deep and superficial portions of the gland. e.) Within the gland. superficial temporal artery and vein. The nerve is just medial to the insertion point. The insertion of the posterior belly of the digastric muscle is identified. have been distinguished. the stylomastoid foramen is subcutaneous. 1-99. Rowe JS Jr. but do not innervate it. Gray SW. The styloid process is an unreliable landmark because of variations in its shape and size. the lower auricle. and cervical. Anatomical Complications in General Surgery. each of which begins at the intertragic notch of the external ear (Fig.g. The trunk of the facial nerve will be found deep and anterior to the center of the fingertip. for all practical purposes. the external auditory canal293 and the tympanomastoid suture.

and reported 5 seropositive patients with bilateral parotid enlargement. A line from the intertragic notch as shown will overlie the temporal branch. We quote from James and Sharma 298 on parotid gland sarcoidosis: Parotid gland sarcoidosis occurs in 6% of patients with sarcoidosis. Most of the benign tumors are located in the superficial lobe and should be excised not by enucleation. indicates the midpoint of a horizontal line drawn from the angle of the mandible to just below the lobe of the ear. B. The stone may be palpated (if large enough) within the mouth.htm 99/125 . a chronic inflammatory condition of the salivary glands (especially the submandibular gland) which cannot be clinically distinguished from a true neoplasm. lacrimal gland enlargement and skin disease. Parotid tumors may be benign or malignant. and presented in the majority in the 20 to 40 year age group. The great auricular nerve may be used as a nerve graft. uveitis. Chronic sclerosing sialadenitis. A. This abscess can be drained through the oral cavity or occasionally by a vertical incision of the skin and elevation of the gland. depressed salivation. Renehan et al. pus will travel to the retromandibular space. Those with multinodular recurrences are at high risk of http://web.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. which triggers pain fibers carried by the auriculotemporal nerve. A line drawn from the intertragic notch to this midpoint overlies the typical course of the cervical branch. slightly commoner in women. In other words. Tunkel et al. Neck Superficial distribution of the facial nerve. and dirty mouth. Patterns of involvement may be pathognomic as in Heerfordt's disease.296 reported a case of Kuttner tumor of the submandibular and parotid glands exhibiting widespread swelling. Malignant tumors should be treated by total parotidectomy.5/24/2014 Print: Chapter 1. dehydration. sacrifice the facial nerve if it is involved with the process. SURGERY OF THE PAROTID GLAND An inflammatory process of the parotid produces severe pain because of the tough unyielding superficial parotid fascia. Williams et al. temporomandibular joint. is also known as Kuttner tumor. Remember the probable cause of parotiditis (the 4 D's): debility. Stone formation within the duct and obstruction is another etiology of abscess formation. particularly intrathoracic. neck dissection should be performed only when there are clinically enlarged nodes or when CT scan gives evidence of nodal involvement.297 stated that HIV infection has broad manifestations affecting the head and neck. but by lobectomy.299 advise neck dissection only for those histologic diagnoses that carry the highest risk of nodal metastases and for those patients whose primary tumor resection might be facilitated by lymphadenectomy. There was widespread involvement of other systems. Abscesses may be formed secondary to pharyngeal perforation or blood-borne infections. Since the parotid tissue extends into the retromandibular area. The yielding deep parotid fascia may rupture. It was bilateral in 24 (73%). any movement of the jaw will produce severe pain.300 analyzed treatment of patients with recurrent pleomorphic adenoma of the parotid gland.uni-plovdiv. indicates the midpoint of a line between the lateral angle of the eye and the anterior surface of the ear. In patients with carcinoma of the parotid gland. peripheral lymphadenopathy. Kelley et al. Schematic representation of the typical positions of the branches of the facial nerve in relation to visible or palpable topographic features of the face. or external auditory canal.

10:257-263. tasting. and the artery is deepest. We strongly advise the surgeon interested in treatment of parotid and salivary cancers to study works of Johns and colleagues. but it is the wrong procedure because of its high recurrence rate. A graft can be used for the facial nerve. In a review of pediatric neoplasms of the major salivary glands. Malignant Salivary Gland Neoplasms in Children (243 from Literature. or infection of the parotid.4 Total 246 100% Source: Shikhani AH.0 Mesenchymal sarcoma 5 2.6 Acinic cell carcinoma 30 12. which supplies the preganglionic fibers for the parotid gland. The treatment of Frey's syndrome is section of the glossopharyngeal nerve. Patients with uninodular recurrences may be adequately treated by surgery alone. Head Neck Surg 1988.302 Why this is so is not known. Neck relapse. employing the following nerves for donor tissue segments: the greater auricular. Johns ME. or smelling.10:257-263. radiation may be indicated to produce atrophy of the gland. Table 1-14.2 Ganglioneuroblastoma 1 0.4 Undifferentiated sarcoma 5 2. with permission.htm 100/125 . penetrating wounds. Microsurgery is the procedure of choice for both. and sural. Most of the tumors of the parotid are benign. Enucleation of the tumor is very tempting. For a salivary fistula. Total parotidectomy for malignant tumors is the treatment of choice despite possible sacrifice of the facial nerve. Shikhani and Johns 304 recommended complete removal of the tumor at initial surgery (Tables 1-13.303 demonstrated the efficacy of postoperative irradiation for improving survival and local control in patients with carcinomas of the parotid and submandibular glands. 18 from Johns Hopkins) Histology Number Percent Pleomorphic adenoma 214 86.2 Lymphoma 3 1.9 Adenoid cystic carcinoma 16 6. Remember that the facial nerve is superficial.2 Neurilemmoma 3 1. Johns ME. Irregular regeneration in the distribution of auriculotemporal nerve fibers causes flushing and sweating to take place when eating. and 1-15).7 Malignant mixed tumor 10 4. they benefit from surgery with radiotherapy. A rare pleomorphic salivary adenoma in an adolescent was reported by Forty and Wake. most of the tumors of all the minor salivary glands are malignant. Benign Salivary Gland Neoplasms in Children (229 from Literature. Tumors of the major salivary glands in children.8 Adenoma 1 0.4 Total 247 100% Source: Shikhani AH. Trauma in the parotid area can produce injury of the facial nerve or division of the parotid duct. with permission. The great auricular is the best because it is located in the same area and because its caliber is almost the same as that of the facial nerve. 1-14. lateral femoral cutaneous.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. North et al. The most common procedure for a benign tumor is removal of the parotid lobe.5/24/2014 Print: Chapter 1.301 The syndrome of Frey (auriculotemporal nerve syndrome) consists of gustatory sweating and flushing of the ipsilateral face following parotidectomy. Head Neck Surg 1988.1 Rhabdomyosarcoma 6 2. If this is not possible for the duct.5 Adenocarcinoma 19 7.6 Squamous cell carcinoma 3 1.uni-plovdiv.2 Undifferentiated carcinoma 22 8.2 Xanthoma 2 0. a vein is under the nerve.305-308 Table 1-13. This condition may be caused by stimulation of the preauricular sweat glands. With inflammatory process and abscess formation an anatomic incision for draining is advised.2 Embryoma 3 1. ilioinguinal.0 Unclassified carcinoma 4 1. 3 from Johns Hopkins) Histology Number Percent Mucoepidermoid carcinoma 122 49.2 Warthin's tumor 5 2 Cystadenoma 5 2 Lymphoepithelial lesion 3 1. http://web. Tumors of the major salivary glands in children.6 Plexiform neurofibroma 8 3. proximal and distal ligation is acceptable.

A traction injury may result in temporary paresis or permanent injury. should this be necessary. Head Neck Surg 1988. Johns ME.8) 4/7 10-51 yrs Total parotidectomy 2 Adenoid cystic carcinoma (parotid) Miscellaneous carcinoma* Sarcoma (parotid) 0 4 yrs 1 (50) 1 (50) 1/2 2 mos-7 yrs Total parotidectomy & RT 3 1 (33.5-18 yrs Excision 9 5 (55. Source: Shikhani AH. They can be preserved only by careful observation and awareness of the previously described anatomy. according to Brenner and Schoeller.5) 1/6 (16. The smaller branches are injured more often and are much less easily sutured.7) 0 2-16 yrs Superior parotidectomy 2 0 (0) 2/2 (100) 0 0.3-3 yrs Excision & RT 3 3 (100) 0 3 6-8 mos RT alone 1 1 (100) 0 1 15 mos *Miscellaneous carcinomas undifferentiated. spinal accessory. Neck Table 1-15. DOD. Spira310 was perhaps the first to anastomose the masseteric nerve to the facial nerve. Tumors of the major salivary glands in children.uni-plovdiv. 1-100). RT.3) 2/3 (66.5 & 7 yrs Acinic cell carcinoma (parotid) Superior parotidectomy 1 0 (0) 1/1 (100) Total parotidectomy 2 0 (0) 2/2 (100) 0 2 & 3 yrs Excision 19 5 (26) 6/7 (85. 1-100. A stimulating electrode can be employed in verifying facial motor branches.5) 7/9 9 mos-8 yrs Excision & RT 8 7 (87. Fig.1) 1 1-14 yrs Excision & RT 5 0 (0) 5/5 (100) 0 1-5 yrs Mucoepidermoid carcinoma (submandibular) Excision & RT 2 1 (50) 2/2 (100) 0 5.5 & 10 yrs Total parotidectomy 4 2 (50) 2/4 (50) 2/4 0. causing muscle spasms when a nerve is contacted.6) 1/3 2-14 yrs Excision 10 8 (80) 1/8 (12.10:257-263. Summary of Treatment and Outcome of 272 Cases in Childhood Salivary Gland Neoplasms Histology Initital Treatment No. of Cases Recurrence NED (%) DOD Follow-Up Pleomorphic adenoma (parotid) Superior parotidectomy 41 8 (19.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck.htm 101/125 . Bleeding from small vessels can result in hematoma. dead of disease. and glossopharyngeal nerves. A large cutaneous nerve of the calf (sural nerve) is often used in this procedure to graft to the contralateral intact nerve.3) 45/50 (90) 1 1-49 yrs Pleomorphic adenoma (submandibular) Excision 21 4 (19) 21/21 (100) 0 3-25 yrs Mucoepidermoid carcinoma (parotid) Superior parotidectomy 13 4 (30. adeno. Nerve Injury The most commonly injured branches of the facial nerve are the buccal and mandibular.3) 2/3 (66. no evidence of disease. Brenner and Schoeller309 reported that the masseteric nerve.5) 3/7 (42. is a possible donor for facial nerve anastomosis to restore function (closure of the mouth and eye) following facial nerve paralysis.5-22 yrs Excision 41 20 (48.6) 5/6 3-9 mos RT alone 2 2 (100) 0 (0) 2/2 4-12 mos Total parotidectomy 3 1 (33. Other nerves used to restore facial nerve function are the hypoglossal. The masseter muscle is denervated but its function.5) 23/25 (92) 0 1-29 yrs Total parotidectomy 14 1 (7. they also have few interconnections with other branches. The facial trunk is large enough for anastomosis of the cut end.8) 16/17 (94. a branch of the mandibular nerve (Fig.6) 1/3 7-22 yrs Total parotidectomy & RT 3 3 (100) 0 3 0. http://web.5/24/2014 Print: Chapter 1. No repair will completely restore function.309 may be taken over by the temporal muscle. and unclassified carcinoma NED.1) 14/14 (100) 0 4-22 yrs Excision 56 22 (39. ANATOMIC COMPLICATIONS Vascular Injury The major vessels crossing the parotid bed must be divided and ligated during parotidectomy. The facial nerve and its branches are obviously in danger during parotidectomy. malignant mixed. radiation therapy.7) 11/11 (100) 0 2-17 yrs Total parotidectomy 7 0 (0) 7/7 (100) 0. with permission.

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Diagram of the mandibular nerve in the region deep to the ramus of the mandible. In this lateral view the otic ganglion, situated on the medial side of the mandibular
nerve, is indicated in outline. The branch of the mandibular to the tensor veli palatini, which passes medially through the otic ganglion, is not shown. (Modified from
Hollinshead WH. Anatomy for Surgeons (2nd ed): Vol.1, The Head and Neck. New York: Harper & Row, 1968; with permission.)

Fournier et al.311 reported that the motor distribution of the mandibular nerve makes it a possibility for a masseteric-facial anastomosis to restore facial
function. They wrote, "The modest results and the side effects of the facio-hypoglossal anastomosis used for facial rehabilitation have led us to consider an
anastomosis between a motor branch of the trigeminal nerve and the facial nerve. Dissection has allowed us to demonstrate that the masseteric nerve offers
the characteristics and the relationships which should make such an anastomosis feasible."
Injury to the auriculotemporal nerve can produce Frey's syndrome, in which the skin anterior to the ear sweats during eating ("gustatory sweating";
considered previously under "Surgery of the Parotid Gland").

Submandibular Glands
EMBRYOGENESIS
The submandibular glands appear at approximately the end of the 6th week. The endoderm and oral epithelium in the floor of the primitive oral cavity are
responsible for the genesis of these glands. They are located lateral to the primitive tongue. Acini are formed around the 12th week. According to
Sperber,312 the glands also begin secreting at this time. The submandibular duct is formed later by the closure of a linear groove.

SURGICAL ANATOMY
The superficial portion of the submandibular gland is about 4 cm long, lying in the submandibular triangle superficial to the mylohyoid muscle. A tongue of
glandular tissue passes deep to the muscle, enveloping its posterior border to form the much smaller deep portion of the gland (see Fig. 1-18).
Important relationships of the superficial portion are: (1) the inferior surface is related to the facial vein and the cervicofacial branches of the facial nerve,
including the marginal mandibular and cervical rami; (2) the lateral surface is related to the facial artery; and (3) the medial surface is related to the
glossopharyngeal, lingual, and hypoglossal nerves.
The deep portion of the submandibular gland is related to the lingual nerve and submandibular ganglion above, and the hypoglossal nerve below (see Fig. 119).
The submandibular (Wharton's) duct emerges from the middle of the deep portion of the gland, crosses the sublingual space, and opens into the mouth on
the side of the frenulum of the tongue. Proximally it lies between the mylohyoid and hyoglossus muscles; distally it lies between the genioglossus muscle and
the sublingual gland.
The lingual nerve, a branch of the mandibular division of the trigeminal nerve (V), has a special relationship to the duct.25 The nerve lies first above and then
lateral to the duct, crossing below and then medial to it (see Fig. 1-19). The danger of injuring the nerve when sectioning the duct is obvious. The
hypoglossal nerve must also be protected inferior to the duct.

Marginal Mandibular Nerve
In about 50 percent of subjects, the mandibular branch of the facial nerve (marginal mandibular nerve) lies beneath the lower margin of the mandible. In the
remainder it lies below the mandible, posterior to the crossing of the facial artery16 (see Fig. 1-15). Ziarah and Atkinson,313 after dissecting 110 facial
halves, also reported that in more than half of their specimens the mandibular branch ran below the mandible and distal to the facial vessels.
It is important to note that the mandibular nerve is multiple in about 80 percent of individuals.17

SURGERY OF THE SUBMANDIBULAR GLANDS
With malignant tumors, total excision is mandatory. Occasionally the lingual and hypoglossal nerves should be sacrificed. With inflammatory process, abscess
formation, or lithiasis a very anatomic incision is advised.

ANATOMIC COMPLICATIONS

Vascular Injury
The vessels most frequently injured during excision of the submandibular glands are the facial (external maxillary) artery and vein. Martin314 suggested that
the facial artery or vein be exposed, sectioned, and ligated well below the edge of the mandible. The distal stump of the vessel is then dissected upward with
upward traction so that the marginal mandibular nerve is carried upward by the loop of the vessel. The artery and vein can be sutured to the underside of
the skin flap. This procedure will ensure ligation of these vessels before they are sectioned inadvertently.

Nerve Injury
Marginal Mandibular Nerve: The procedure outlined above for avoidance of vascular injury completely protects the mandibular nerve from subsequent injury.
If the mandibular branch of the facial nerve is injured it results in a flattening of the lower lip on the affected side. If a nerve stimulator is used to identify the
nerve, the anterosuperior portion of the platysma may contract. Depression of the corner of the mouth may also be observed. Dingman and Grabb17
discussed this response.
Hypoglossal Nerve: See "Radical Neck Dissection" following in this chapter.
Lingual Nerve: See "Radical Neck Dissection."

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Sublingual Glands and Other Salivary Glands
EMBRYOGENESIS
The sublingual glands appear around the 8th week. They originate from several epithelial buds of endodermal origin which are located at the paralingual
sulcus. The buds form multiple ducts by canalization.

SURGICAL ANATOMY
The paired sublingual gland (Figs. 1-101, 1-102) is an amygdaloid (almond-shaped), flat and narrow gland, smaller than the other major salivary glands
(parotid and submandibular). The sublingual gland is located under the mucosae of the floor of the mouth. Its boundaries are:
Superior: mucosa of the oral floor
Inferior: mylohyoid muscle
Anterior: sublingual gland of the other side
Posterior: deep process (anterior prolongation) of the submandibular (submaxillary) gland; rarely, this may be affixed to a secondary inflammatory process
Medial: lingual nerve, submandibular duct, and genioglossus muscle
Lateral: medial surface of the lower mandible

Fig. 1-101.

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Superficial and deep structures in the sublingual region. ("Right" and "left" indicate the side of the drawing.) A, Superficial Structures. The mucosa is intact on the
left; on the right, the region has been cleared of the vessels and nerves. B, Deep Structures. The vessels and nerves have been removed on the left, and on the
right the vessels and nerves are in situ.

Fig. 1-102.

Lateral view of the sublingual region. The body of the mandible has been removed.

This mucous gland has multiple ducts: 10 to 30, according to O'Rahilly,315 and 8 to 20, according to Gray's Anatomy.54 The ducts drain directly into the oral
cavity on the sublingual fold, with some of them entering the submandibular duct.

SURGERY OF THE SUBLINGUAL GLANDS AND OTHER SALIVARY GLANDS
A calculus may form within the substance of the gland (sialolith). The calculus can be removed through a mucosal incision, or the gland in toto can be
removed. The danger zone is the medial boundary where the submandibular duct and lingual nerve are located.
Another pathologic condition is the formation of a cyst or mucocele, the well-known ranula. Origination of the ranula is usually in the sublingual glands or
minor salivary glands, although it can appear in the submandibular duct. Removal of the cyst or the cyst plus the sublingual gland is advisable if partial
removal of the roof is not successful.
It is not within the scope of this book to present all the salivary glands, especially the so-called minor salivary glands (lingual, labial, buccal, palatal, etc.).
These are located in the mucosa or submucosa of the oral cavity. They are ductless or have minute, very short ducts.

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In other sections of this chapter we have discussed structures adapted to new functions: the thyroid and parathyroid glands and the ultimobranchial bodies. only the dorsal portion of the first cleft and first pouch persist —as the external auditory meatus from the former and the middle ear and eustachian tube from the latter. tympanic membrane.316 and Paulino and Huvos. some of which represent the primordia of the respiratory apparatus of our aquatic vertebral ancestors. SURGICAL ANATOMY Fistulas Fistulas are patent ductlike structures that have both external and internal orifices. 1983. Rowe JS Jr. They are remnants of the ventral portion of the first branchial cleft (Fig. and a duct that provides the pathway for the saliva. New York: McGraw-Hill. Neck Since most tumors developing in sublingual and other salivary glands are malignant. arytenoid cartilages Ultimobranchial body (parafollicular cells of thyroid) VI 6th (proximal pulmonary artery. These fistulas lie anterior to the facial nerve.73 characterized salivary gland carcinomas as "infrequent in any single surgeon's experience.317 BRANCHIAL REMNANTS EMBRYOGENESIS Between the fourth and sixth weeks of gestation. Table 1-16. Meckel's cartilage I (hyomandibular) II (hyoid) Dorsal: auditory canal. In mammals these structures become rearranged and adapted to new functions. submandibular. Johns et al. distal ductus arteriosus) Cysts? Tracheal cartilage Source: Skandalakis JE. lesser horn of hyoid bone II III Pharyngeal and palatine tonsils 3rd IX III IV 4th (left aortic arch. middle ear. right brachiocephalic) X IV Cysts. Gray SW. en bloc resection is advised. with permission. and fistulas Posterior third of tongue. lingual tonsil Ventral: greater horn of hyoid bone Dorsal: inferior parathyroids Cysts. myoepithelial cells covering the acinar cells. Ventral: thymus sinuses (rare) Epiglottis. or they disappear. Here we are concerned with structures that normally disappear during embryonic life. leaving only occasional vestiges (Table 1-16).bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Cervicoauricular fistulas extend from the skin at the angle of the jaw. 1-103). Fig.htm 105/125 . stylohyoid ligament. Derivatives of Branchial Arches and Pouches Branchial Arch Derivatives Pouch and Cleft Aortic Arch I (maxillary and mandibular) 1st (transitory) Cranial Fleshy Structures Nerve Skeletal Structures V Dorsal: incus Anterior two-thirds of tongue Anomalous Remnants Ventral: malleus. which consists of acinar cells.uni-plovdiv. Each of these glands is composed of parenchymal elements (lobules which form lobes) and connective tissue. and sublingual glands is the same.5/24/2014 Print: Chapter 1. sinuses. base of tongue Ventral: thyroid cartilage Dorsal: superior parathyroids Cysts? Ventral: thymus V 5th (transitory) X (Rare) Ventral: cricoid. These are the ectodermal clefts and the endodermal pouches of the pharynx. Anatomical Complications in General Surgery. The basic anatomic and physiologic unit is the salivon." HISTOLOGY AND PHYSIOLOGY OF THE SALIVARY GLANDS The histology of the parotid. the embryonic foregut changes from a flattened tube into a complicated series of structures. The histochemistry and morphology of oncocytic and oncocytoid tumors of the salivary gland was studied by Johns et al. 1-103. and may open into the external auditory canal. http://web. Of these gill-like organs. eustachian tube 2nd (transitory) VII Ventral: cervicoaural fistula Dorsal: stapes Ventral: styloid process.

) Lateral cervical fistulas almost always arise from the ventral portion of the second branchial cleft and pouch. (Modified from Skandalakis JE. Fig. It enters the pharynx on the anterior surface of the upper half of the posterior pillar of the fauces (Fig.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Gray SW. 1-104. New York: McGraw-Hill. http://web. in front of the hypoglossal nerve. It may open into the supratonsillar fossa or even into the tonsil itself. with permission. The path is upward through the platysma muscle and deep fascia. This is a persistent remnant of the ventral portion of the first branchial cleft. Neck Congenital cervicoaural fistula or cyst. The tract may or may not open into the external auditory canal. and between the external and internal carotid arteries. They originate on the lower third of the neck on the anterior border of the sternocleidomastoid muscle. The orifice may be pigmented.htm 106/125 . 1983.uni-plovdiv. Rowe JS Jr.5/24/2014 Print: Chapter 1. Above the hyoid bone the track turns medially to pass beneath the stylohyoid and the posterior belly of the digastric muscle. 1-104A). Anatomical Complications in General Surgery.

New York: McGraw-Hill. Cysts on the pharyngeal wall deep to the carotid arteries are usually of branchial cleft origin. Superficial cysts lie at the edge of the sternocleidomastoid muscle. C. jugular vein. Anatomical Complications in General Surgery.318 External sinuses usually arise at the anterior border of the sternocleidomastoid muscle and end in a cystic dilatation. Gray SW. sinuses.) Sinuses Internal sinuses are blindly ending spaces that extend outward from openings in the pharynx. 1983. These are of branchial cleft origin and are lined with stratified squamous epithelium. Rowe JS Jr. (Modified from Skandalakis JE.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. 1104C). 1-105. Complete fistula. Anatomical Complications in General Surgery. V. between the muscle and the jugular vein. superficial. in the bifurcation of the carotid artery. at the border of the sternocleidomastoid muscle. External (cervical) and internal (pharyngeal) sinuses. undetected. 1-105). A. Rowe JS Jr.uni-plovdiv. in the pharyngeal wall. II. and fistulas related to the branchial remnants. http://web. Gray SW. Type IV is from the second pouch. A. They are lined with ciliated epithelium unless inflammatory or pressure changes have occurred (Fig. carotid artery. Many such sinuses result from an infected cyst or previous incomplete excision of a cyst (Fig.5/24/2014 Print: Chapter 1. Incomplete closure of the second branchial cleft of the pouch may leave cysts: Type I. external sinuses are blindly ending spaces that extend inward from openings in the skin. Deeper cysts lie on the jugular vein or in the bifurcation of the carotid artery (Fig. Type III. Skandalakis and Gray83 consider these embryonic structures in greater detail.) SURGERY OF THE BRANCHIAL REMNANTS Surgery is the treatment of choice for all cysts. sternocleidomastoid muscle. Cyst of branchial cleft origin lying in the carotid notch. (Modified from Skandalakis JE. M. B. and III are of second cleft origin. 1-104B). Fig. New York: McGraw-Hill. Type II. 1983. Types I. Internal sinuses are usually asymptomatic and. with permission. Neck Track of a second pouch and cleft fistula passing from the tonsillar fossa of the palatine (faucial) tonsils to the neck. Cysts Cysts are spherical or elongated spaces lying in the track of a branchial pouch or cleft and have no communication with the pharynx or skin. Type IV. hence. with permission.htm 107/125 .

together with all nonessential structures and their lymph nodes. anterior jugular. When removing the cyst.uni-plovdiv. Kim et al. phrenic nerve. facial nerve. Structures in these categories are listed in Table 1-17. nonlymphatic tissue falls into three categories: (1) structures that can be sacrificed with impunity. recurrent laryngeal nerve. digastric. thoracic duct Nerves Anterior cutaneous C2-C3. the SCM muscle. Neck Branchial remnants originating in the piriform recess can cause recurrent fistulas or abscesses in the neck. Inadequate Procedures Drainage or aspiration of branchial cysts is useless. Remember that this is at or near the tonsillar fossa. lingual. cervical sympathetic nerve. the surgeon must be careful to protect the nerve. and internal jugular. stylohyoid All other muscles Vessels External jugular vein. jugular vein lingual artery External carotid artery. ansa hypoglossi.5/24/2014 Print: Chapter 1. In addition to lymphatic tissue. subclavian artery and vein.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. hypoglossal nerve. posteriorly by the anterior border of the trapezius muscle. and (3) structures that must be preserved unless directly invaded by cancer. ANATOMIC COMPLICATIONS Vascular Injury The external and internal carotid arteries just above the bifurcation of the common carotid artery are especially prone to injury while performing excision of the branchial remnants. supraclavicular C3-C4. Removal of all epithelial tissue is the only cure. which must be removed as completely as possible. vagus nerve. The following veins must be avoided or ligated during excision of the branchial remnants: the external jugular. lower pole of parotid gland None Thyroid gland. Table 1-17.319 recommend chemocauterization of the internal opening to avoid recurrence from inadequate removal of the fistula tract. and anteriorly by the midline. below by the clavicle. The bed of a radical neck dissection is bounded above by the inferior border of the mandible.htm 108/125 . and fat. parathyroid glands Muscles Omohyoid. Nerve Injury A first cleft sinus or cyst passes over or under the facial nerve below and anterior to the ear. http://web. internal carotid artery. superior thyroid artery. common facial. lingual nerve. superior laryngeal nerve. great auricular nerve Mandibular branch of facial nerve. cranial nerve XI. and will sooner or later result in infection. brachial plexus. Uncontrolled bleeding can be a problem. carotid sinus nerves. because a second cleft cyst or the path of a second cleft fistula will lie in the crotch of the bifurcation. facial artery Internal and vein. RADICAL NECK DISSECTION INTRODUCTION A radical neck dissection involves complete excision of the primary lesion. especially for cosmetic reasons. collecting lymph trunks. The cyst may displace the nerve either upward or downward. nerves to rhomboid and serratus muscles a Unless Spinal accessory nerve invaded by cancer. sternocleidomastoid Platysma. By definition radical neck dissection involves the levels of lymph nodes I to V. Synopsis of Radical Neck Procedures Structures May be Sacrificed Controversial Must be Preserveda Organs Submaxillary gland. Several nerves will be found above the pathway of a second cleft or pouch branchial fistula: Mandibular branch of the facial nerve (protection of this nerve has been considered under "Submandibular Glands: Anatomic Complications") Cervical branch of the facial nerve (the skin should be incised 4-5 cm below the mandibular angle) Spinal accessory nerve (may be injured when trying to free a cyst or fistulous tract from the sternocleidomastoid muscle) Descendens hypoglossi (superior root of the ansa cervicalis) (may be cut if necessary) Hypoglossal nerve (the fistula crosses the nerve above the bifurcation of the common carotid artery) Superior laryngeal nerves (see "Anatomic Complications of Thyroidectomy: Nerve Injury" for discussion of effects of injury) Vagus nerve (lies parallel to the carotid artery [the fistula crosses the nerve near the level of the carotid bifurcation]) Organ Injury The pharyngeal opening of a fistula or an internal sinus must be closed without producing a large iatrogenic defect. (2) structures whose sacrifice is controversial. fascia. and the internal jugular vein.

New York: McGraw-Hill. and supraclavicular nerves must be sacrificed. and shoulder. The report indicated that the recurrence and survival rates were similar with both procedures. The Brazilian Head and Neck Cancer Study Group320 presented results of a trial comparing management of oral squamous carcinoma using modified radical classical neck dissection and using supraomohyoid neck dissection. Some would sacrifice the muscle routinely. Anatomical Complications in General Surgery." Triangles Anterior Triangle Submental triangle: Remove the entire contents. Rose JS Jr. http://web. lesser occipital nerve. the carcinoma is so widely disseminated that nothing is gained by further surgical procedures.5/24/2014 Print: Chapter 1. greater auricular nerve.321 There is disagreement about the need for sacrificing the platysma muscle. SURGICAL ANATOMY Fascia Superficial Cervical Fascia The transverse cervical nerve. because lymph nodes and lymphatic vessels are distributed primarily in the connective tissue between the layers of the fascia. Fig. Gray SW. Submandibular triangle: Remove the submandibular gland and lymph nodes."23 Deep Cervical Fascia The deep cervical fascia must be removed as completely as possible. Supraomohyoid neck dissection was recommended as standard elective treatment for T2-T4 oral squamous cell carcinomas. The carotid sheath and the internal jugular vein also should be sacrificed. Because of the morbidity of sacrifice of cranial nerve XI.uni-plovdiv. The final result is shown in Figure 1106.322 reported that "the arterial blood supply of the lower third of the sternocleidomastoid muscle is constantly provided by a branch of the suprascapular artery. when nodes in the area are not enlarged a modified neck dissection is attempted. Others believe that preservation of the muscle minimizes scarring and "that once superficial lymphatics are involved. The result is anesthesia of the posterior scalp. Kierner et al. High ligation of the vein is facilitated by removal of the lower pole of the parotid gland. The great auricular nerve and all superficial branches of the cervical nerves should be cut. neck.htm 109/125 . Radical neck dissection must be planned as a curative procedure.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. with permission. Carotid triangle: Remove the internal jugular vein. 1-106. All lymph nodes along the internal jugular vein must be removed. The sternocleidomastoid muscle is used in reconstruction of radical procedures of the neck. 1983. therefore knowledge of the blood supply of the muscle perhaps will minimize the risk of muscle necrosis. Neck Source: Skandalakis JE.

Between the internal jugular vein and the common carotid artery lies the ansa cervicalis. Ligate the external jugular vein close to the subclavian vein. the brachial plexus. Gray SW. Anatomical Complications in General Surgery. It may be cut with impunity.) Posterior Triangle Remove all tissue above the spinal accessory nerve without injuring the nerve. Rowe JS Jr. Lingual Nerve http://web. It contains several structures that must be identified and saved if possible: the nerves to the rhomboid and serratus anterior muscles. Therefore it should be protected not only for functional reasons but also for cosmetic reasons. New York: McGraw-Hill. ligate them.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. Neck The completed radical dissection of the neck. They should be preserved if possible. (Modified from Skandalakis JE. Remaining structures may be removed if they are involved in malignant growth. deep to the sternocleidomastoid muscle and posterolateral to the internal jugular vein. to avoid an abnormal facial expression and a highly asymmetrical mouth corner. the subclavian artery and vein. but if they have been injured. Some lymphatic trunks may open independently into the subclavian or jugular veins. and transect the sternocleidomastoid and omohyoid muscles. Note The cervical branch of the facial nerve can be cut with impunity since it innervates only the platysma muscle.5/24/2014 Print: Chapter 1. which innervates the strap muscles of the neck. The area beneath the spinal accessory nerve is the "danger zone"23 of Beahrs. The object of dissection in this area is to remove completely the transverse cervical (inferior horizontal) and spinal accessory chains of lymph nodes. with permission. Nerves Marginal Mandibular Nerve The marginal mandibular nerve is located in a horizontal (transverse) orientation. and the phrenic nerve with the anterior scalene muscle between.uni-plovdiv.htm 110/125 . free the nerve from the underlying tissue. The thoracic duct on the left and the lymphatic duct on the right lie in a mass of areolar connective tissue. An incision in the skin 4-5 cm below the mandibular angle will protect the nerves. This nerve is on or in the carotid sheath medial to the internal jugular vein. The marginal branch innervates the muscles of the lower lip (quadratus labii inferioris and mentalis). With blunt dissection. 1983. just under the platysma muscle and above the deep cervical fascia. It is found just above and superficial to the facial artery and vein.

5 cm) in the subcutaneous tissue of the posterior triangle. and 4th cervical nerves.331 stated that the exact motor innervation of the trapezius muscle is controversial. the hypoglossal nerve passes into the substance of the tongue. that is. of which the vagus is a part. under and deep to the submandibular gland on its way to the tongue. and cited the occurrence of muscle paralysis "without discernible cause. They noted that with loss of the nerve. the carotid triad. This is the reason that the nerve is so vulnerable in this area. http://web. we advise that the knife not be used after making the skin incision. however. hypoglossal nerve.27 The nerve should be protected. Instead. When the hypoglossal nerve is used to replace the injured facial nerve. paralysis of the trapezius resulted.334 lymph node biopsy was the predominant reason for injury to the accessory nerve in 37 cases. deep to the prevertebral fascia. 3rd. This artery reaches the muscle parallel with. the hypoglossal nerve provides motor supply to all of the musculature of the tongue except the palatoglossus. The result is that when protruding. Therefore. Beahrs23 stated that the hypoglossal nerve may be injured in this location. According to King and Motta. but the superficial layer (investing layer) is very thin and occasionally unnoticeable. but inferior to. using a hemostat. the branch from the spinal accessory to the trapezius may diverge from the SCM. it passes deep to the duct to reach the tongue.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck. this vessel can be helpful in locating the nerve. Thus. Brown et al. and accidentally severed during lymph node excisional biopsy in the posterior triangle. beneath the posterior belly of the digastric muscle. Spinal Accessory Nerve The pathway of this nerve in the posterior triangle is enigmatic and peculiar. it gives off the sternocleidomastoid artery. Presumably these contributions are sensory in function.333 presented a very good description of the results of injury to the accessory nerve. Crossing superficial to the nerve are the lateral branches of the thyrocervical trunk. the patient is advised to move the tongue to the injured side when trying to smile.htm 111/125 . Phrenic Nerve The phrenic nerve is located on the ventral surface of the anterior scalene muscle. We have also seen the nerve end at the posterior border of the sternocleidomastoid muscle. and the duct of the submandibular gland travel together above (deep to) the mylohyoid muscle. Vagus Nerve Very rarely the vagus nerve is damaged during radical neck dissection. the tongue deviates to the paralyzed side. However. Three to four lymph nodes are very closely associated with the spinal nerve in the posterior triangle. The lingual artery passes deep to the hyoglossus muscle to enter the substance of the tongue.324 noted that the accessory nerve is vulnerable to injury despite careful preservation during surgical dissection. Donner and Kline335 noted that the spinal accessory nerve was the nerve most commonly injured by accident. or bifurcate and trifurcate very close to the posterior border of the sternocleidomastoid muscle. such as the hypoglossal vena comitantes and the lingual artery. Neck Lingual Nerve The lingual nerve. The lingual nerve provides general sensory and taste fibers to the tongue. when the spinal accessory ends in the SCM muscle. some patients have trapezius function even when cranial nerve XI is sacrificed.329. This nerve has several fellow travelers. moving obliquely toward the anterior border of the trapezius muscle where the spinal accessory nerve disappears under the trapezius. joining the branch from C3. The occipital artery very consistently crosses superior to the hypoglossal nerve from anteromedial to posterolateral. In our experience. Zibordi et al. Gordon et al. Its position can be approximated by a line drawn from a point two-thirds of the distance up the posterior border of the sternocleidomastoid and by another point one-third of the distance up the anterior border of the trapezius. the point of entrance of the spinal accessory nerve into the SCM. the nerve may be fixed with one lymph node. The spinal accessory receives contributions from the 2nd. distributing branches to its musculature. presumably due to the complexity of its contributions and branching patterns. We noticed the nerve very close to the skin (0. As it does so. passes horizontally forward in the upper part of the neck and enters the floor of the mouth by passing deep to the mylohyoid muscle. Carney and Anderson323 reported hypoglossal nerve and internal carotid artery entrapment resulting from an inflammatory process of the surrounding lymph nodes in the area where the nerve is very close to the artery. its sacrifice is necessary.330 The double layer (superficial and deep) of fascia in this area is also peculiar.5/24/2014 Print: Chapter 1. Hypoglossal Nerve The hypoglossal nerve lies external to the hyoglossus muscle. because of contributions from C3-C5. excluding the palatoglossus. With severe lymphadenitis. is easily recognized. anteriorly. with drooping and internal rotation of the shoulder. the transverse cervical and suprascapular arteries. Even though the nerve is posterior to the common carotid artery and internal jugular vein and not readily seen. Soo et al. Other workers325-327 also emphasized the vulnerability of the nerve to injury. the most inferior member of the trio. However. Decker and DuPlessis336 reported that the occipital artery crossing the hypoglossal nerve gives off a sternomastoid branch which follows the spinal accessory nerve. The lower contributions can occur in the posterior triangle. the lingual artery may be located above or below the nerve. Unilateral paralysis of the hemidiaphragm after division of the phrenic nerve is tolerated well. The hypoglossal nerve. if the vagus nerve is involved with tumor. Coursing beside the hypoglossal nerve.332 recommended changing the name of the spinal accessory nerve to the spinal accessory nerve plexus." O'Brien328 reviewed the indications for modified cervical dissections and methods of sparing the spinal accessory (and other) important regional nerves. The spinal accessory nerve is said to be located between two layers of fascia and separated from the levator scapulae by a heavy dense fascia. The spinal accessory nerve innervates practically all segments (regions) of the muscle. We have seen this occasionally. thereafter descending to the trapezius.uni-plovdiv.5-1. the innervation of the trapezius is via C3. which is supplied by the vagus. carefully separate the tissues in the pathway of the nerve from the posterior border of the sternocleidomastoid muscle. The lingual nerve is first seen at a higher level than the submandibular duct. We have seen the spinal accessory nerve bifurcate and trifurcate prior to its disappearance under the trapezius. Brown et al. This trio can be seen after retracting the posterior border of the mylohyoid muscle. it is quite vulnerable in the posterior triangle. This is due to paralysis of all the intrinsic and extrinsic muscles of the tongue. Primary repair of the hypoglossal nerve by microsurgical technique is possible if the injury is recognized during surgery. The deep layer (prevertebral fascia) is dense.332 also observed that the accessory nerve was easily removed along with a lymph node to which it was densely adherent. However. Thereafter.

htm 112/125 . If such pressure cannot be avoided. Puttini et al. Pneumothorax and pneumomediastinum also have been reported." However.339 Nerve Injury Spinal Accessory Nerve Section of the spinal accessory nerve (XI) denervates the trapezius muscle. Of the patients undergoing compulsory ligation.339 have warned of the danger of air embolism through the internal or external jugular veins or the subclavian vein. The axiom by Moore et al. .340 recommend early operative intervention if the peak 24-hour drainage is greater than 1000 mL without a prompt response to medical management.—Southwick and Slaughter337 Vascular Injury Kerth and associates321 stated that the vessels injured in a radical neck dissection are (in order of frequency): the internal and external jugular veins. Neck Thus. then repair should be done as soon as possible. The subclavian vein is the direct continuation of the axillary vein. limiting abduction of the arm and elevation of the shoulder. Tindall.343 reported that all patients with unilateral internal carotid artery occlusion had recurring episodes of focal cerebral ischemia. The postoperative course of superficial temporal artery-middle cerebral artery anastomosis was uneventful in 23 patients (82%).347 in the same comments. Bilateral ligation or excision must be undertaken with caution.344 reported operative morbidity and mortality of 4. pharyngeal. infiltration of the area with Xylocaine is suggested. Complete unilateral obstruction of the internal carotid artery carries a great chance of mortality. . If the fistula does not resolve.5/24/2014 Print: Chapter 1.342 stated that 23% of patients who underwent elective carotid artery ligation suffered strokes and 17% died. this vessel can be helpful in locating the nerve. Hans-Peter Richter345 agreed with Gabel and Nunley346 that the results of nerve repair are far worse if repair is delayed more than 4 months after the initial injury.338 Unilateral ligation of external and internal jugular veins produces transient cyanosis and edema of the head. pterygoid. an excellent prognosis could be anticipated. Martin314 considered simultaneous bilateral ligation "standard procedure in selected cases. and carotid artery. it must be protected from injury. Information about complications of injury to the thoracic duct will be found in the chapter on the lymphatics. She stated that if it could be repaired early. thoracic duct. and. External Laryngeal and Recurrent Laryngeal Nerves http://web.bg/stu1104541018/docs/res/skandalakis'%20surgical%20anatomy%20-%202004/Chapter%2001_%20Neck." If removal of the nerve is considered unnecessary. If the injury is recognized postoperatively. and thereby injured readily. elective ligation is preferable to ligation after exsanguinating hemorrhage.uni-plovdiv. deep cervical. Zarem would allow at least one month between ligations to permit the vertebral veins to compensate for increased venous flow. and occipital venous plexuses. Internal and External Jugular Veins The internal jugular vein should be ligated as close to the subclavian vein as possible. Schmeidek et al.every effort should be made to preserve the integrity of this vessel [carotid artery]. Zarem339 calculated that there is a 20 percent mortality rate if ligation of both sides is done simultaneously. Carotid Artery Many individuals will tolerate unilateral obstruction of the carotid artery. Nussenbaum et al. merely 1-1. esophageal. from the work of several authors. The sural nerve can be used as a graft if an end-to-end anastomosis is not possible. In comments to Donner and Kline. The vein will then retract under the clavicle. Moore et al. Thoracic Duct Postoperative cervical chyle fistula may complicate neck dissection. The most important of these is the vertebral plexus." There may be "winging of the superior angle of the scapula. Subsequent wasting of the muscle results in a "dropped shoulder. Too much traction on the internal jugular vein can result in a tear at its lower end. The actual mortality rate from air embolism is not known. It is related to the first rib and receives the external jugular vein at the area opposite the middle of the clavicle. They advise that persistent low-output drainage after 10 days is associated with a prolonged management course and treatment-related complications. Pressure from manipulation of the carotid sinus at the bifurcation of the carotid artery can result in serious hypotension. is worth reprinting here: .337. Southwick and Slaughter337 mentioned a case in which the common carotid artery and the vagus nerve were accidentally included in a ligation of the internal jugular vein. Repair after the 3rd or 4th month following injury will not be successful. Two patients out of 4 with bilateral carotid artery ligations survived without complications.5 cm from the surface of the skin. 50% suffered strokes and 38% died. if its rupture is deemed inevitable. ANATOMIC COMPLICATIONS Those who undertake [radical neck dissection] should be aware of the vital importance of an accurate anatomic knowledge of the field before accepting the responsibility of the treatment of a patient with metastatic disease involving the neck area. greater auricular nerve graft is often used. If injury is recognized in the operating room. Gregor341 advocates total parenteral nutrition to control fluid and protein loss while avoiding flow of chyle. Venous return will then be through the vertebral. requiring the midportion of the bone to be removed in order to reach and ligate the vein. further observed that the nerve was very superficial. fibrin glue with mesh and muscle flaps is usually successful in achieving closure. but this tolerance cannot always be determined prior to operation. end-to-end microsurgical anastomosis is the procedure of choice. Gordon and colleagues324 reported 17 cases of operations on the posterior triangle in which nerve injury occurred in spite of care taken to prevent it.1% in cases of clinical carotid stenosis with contralateral stenosis. Immediate suturing of the veins is mandatory. Subclavian Vein Several authors321. subclavian vein.

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