Anterior Triangle & Root of the Neck Anat 12A: Head and Neck

Dr. Pio Renato F. Villacorta Exam #1

25/01/2019 Trans #4

OUTLINE Landmarks
I. Introduction V. Carotid Triangle
II. Anterior Cervical Region A. Boundaries
A. Landmarks B. Contents
B. Vertebral levels VI. Muscular Triangle
C. Boundaries A. Boundaries
D. Layers B. Contents
E. Muscles VII. Root of the Neck
III. Submental Triangle A. Boundaries
A. Boundaries B. Contents
B. Contents VIII. Prevertebral Muscles
IV. Submandibular Triangle !
A. Boundaries Figure 3. Surface anatomy of the neck.
B. Contents
1. Mental protuberance - chin
2. Hyoid bone - lies at the level of the C3 vertebra in the angle
I. INTRODUCTION between the mandible and the thyroid cartilage; suspended
by muscles
3. Laryngeal prominence (Adam’s apple) - produced by the
meeting of the laminae of the thyroid cartilage at an acute
angle; more visible in post-pubertal males
4. Cricoid cartilage - indicates the level of C6 vertebra,
junction of larynx and trachea, and junction of pharynx and
esophagus
5. Trachea - tracheal rings can be found below the cricoid
cartilage
! 6. Jugular notch or Suprasternal notch - concave center of
Figure 1. Right anterolateral view of cervical regions of the neck. the superior border of the manubrium
(D) Anterior cervical region.. 7. Mandible - lower jaw
8. Mastoid process - part of temporal bone located postero-
The Neck inferior to the external acoustic meatus opening
• transition between base of cranium and clavicles 9. Sternocleidomastoid - muscle that separates the anterior
• major conduit for structures passing between head and trunk triangle from the posterior triangle.
• vulnerable region due to lack of bony protection
• contains many vital structures such as muscles, glands,
arteries, veins, nerves, lymphatics, trachea, esophagus, and Verterbral Levels
vertebrae
• Main arterial blood flow: Carotid arteries
• Principal venous drainage: Jugular veins
• Main lymph drainage: Cervical lymph nodes
• It is divided into 4 major regions:
→ Sternocleidomastoid region
→ Posterior cervical region
→ Lateral cervical region (posterior triangle)
→ Anterior cervical region (anterior triangle)

II. ANTERIOR CERVICAL REGION !

Figure 4. Lateral view of bones and cartilages of the neck.

1. Hyoid Bone (C3)

2. Thyroid cartilage (C4 & C5)
3. Cricoid cartilage (C6)

The Superior parathyroid glands can also be found at the

level of C6 vertebra and it maintains the amount of calcium in
the blood. Without it, calcium in the blood will drop below
normal levels, which is a condition known as hypocalcemia.
!
Figure 2. Cervical triangles.
Boundaries
• Can be subdivided into 4 smaller triangles by digastric and
1. Anterior: Medial line of the neck
omohyoid muscles:
2. Posterior: Anterior border of sternocleidomastoid (SCM)
→ Unpaired: Submental triangle
3. Superior: Inferior border of the mandible
→ Paired: Submandibular triangle, Carotid triangle, and
4. Apex: Jugular notch in manubrium
Muscular triangle
5. Roof: Subcutaneous tissue containing platysma
6. Floor: Pharynx, larynx, and thyroid gland
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ANAT 12AB: Anterior Triangle and Root of the Neck Exam #1 - Trans #4

Layers Table 1. List of infrahyoid muscles.

Muscles Origin Insertion Innervation Action

Omohyoid Scapula Ansa

Hyoid cervicalis
bone
Sternohyoid from
Manubrium cervical Fixes or
of sternum Thyroid plexus (C1- depresses
Sternothyroid hyoid
cartilage C3)
bone
C1 (via
Thyroid Hyoid
Thyrohyoid hypoglossal
! ! cartilage bone n. - CN XII)
Figure 5. Cross section of the neck.
Table 2. List of suprahyoid muscles.
1. Platysma
→ broad, thin sheet of muscle in the subcutaneous tissue
(superficial cervical fascia) of the neck Muscles Origin Insertion Innervation Action
→ supplied by cervical branch of facial nerve (CN VII)
→ derived from mesenchyme in the 2nd pharyngeal arch of Mastoid
the embryo notch
2. Superficial Cervical Fascia (posterior
Facial and
→ layer of fatty connective tissue that lies between the belly) and
Digastric mandibular
digastric Depresses
dermis of the skin and the investing layer of deep cervical fossa nerves
fascia mandible
(anterior against
→ contains cutaneous nerves, blood and lymphatic vessels, belly) resistance
superficial lymph nodes, and variable amounts of fat when
→ contains the platysma anterolaterally Stylohyoid
Styloid Hyoid bone Facial infrahyoid
3. Deep Cervical Fascia process nerve muscles
→ it consists of 3 fascial layers: Mandibular fix or
Medial
▪ Investing Mylohyoid body of nerve depress
▪ Pretracheal mandible hyoid bone
▪ Prevertebral
→ supports the cervical viscera, muscles, vessels, and deep Anterior Nerve to
lymph nodes Geniohyoid body of geniohyoid
→ it condenses to form the carotid sheath around common mandible (C1-C2)
carotid arteries, internal jugular veins and vagus nerves
(CN X)
III. SUBMENTAL TRIANGLE
Boundaries
Muscles

! !
Figure 6. Suprahyoid and infrahyoid muscles. Figure 7. Submental triangle (dashed lines).

1. Infrahyoid muscles 1. Inferior: Body of the hyoid

→ inferior to hyoid 2. Lateral: Right and left anterior bellies of the digastric
→ long strap-like muscles on each side of neck muscles
→ used for swallowing and speech 3. Floor: Two mylohyoid muscles which meet in a median
2. Suprahyoid muscles fibrous raphe
→ superior to hyoid 4. Apex: Mandibular symphysis or symphysis menti (site
→ shorter strap-like muscles on each side of the neck where halves of mandible meet at infancy)
→ used for swallowing and speech 5. Base: Hyoid
→ constitutes the substance of the floor of the mouth
Contents
1. Several small submental lymph nodes - first line of
defense in the oral cavity
2. Small veins that unite to form the anterior jugular vein
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IV. SUBMANDIBULAR TRIANGLE 2. Carotid body - It is a chemoreceptor that monitors the level
of oxygen in the blood. Innervated by CN IX (via the carotid
Boundaries sinus nerve) and CN X.
3. Common carotid artery (CCA)- its terminal branches are
ECA and ICA
→ Right CCA begins at bifurcation of brachiocephalic trunk
→ Left CCA ascends from the arch of the aorta into the neck
4. External carotid artery (ECA) - supplies blood to the head
and neck. It has 6 branches:
→ Ascending pharyngeal a.
→ Occipital a.
→ Posterior auricular a.
→ Superior thyroid a.
→ Lingual a.
→ Facial a.
5. Internal carotid artery (ICA) - no branches in the neck; it
! supplies the brain and its meninges
Figure 8. Submandibular triangle (dashed lines).
6. Internal jugular vein - drains blood from the brain, anterior
face, cervical viscera, and deep muscles of the neck. It has
1. Found in between inferior border of the mandible and the 5 tributaries:
anterior and posterior bellies of the digastric muscle → inferior petrosal sinus
2. Floor: mylohoid and hyoglossus muscles, and the middle → facial and lingual v.
pharyngeal constrictor → pharyngeal v.
→ superior and middle thyroid v.
Contents → occipital v.
1. Structures 7. Vagus nerve (CN X)
→ Submandibular gland - nearly fills the triangle 8. Ansa cervicalis
→ Submandibular lymph nodes - lies on superficial surface 9. Deep cervical nodes
of submandibular gland
→ Parotid gland - inferior portion
2. Nerves
→ Hypoglossal nerve (CN XII) - provides motor innervation
to intrinsic and extrinsic muscles of the tongue
→ Cervical branch of CN VII
→ Mandibular branch of CN VII
→ Nerve to mylohyoid (branch of CN V3, also supplies
anterior belly of digastric)
3. Arteries
→ Facial artery - branch of external carotid artery (ECA) that
supplies blood to the muscles of the face
→ Lingual artery - branch of ECA that supplies blood to the !
tongue Figure 10. Medial view of right carotid artery.

V. CAROTID TRIANGLE Neurovascular structures in the carotid triangle are

surrounded by the carotid sheath. The main arterial vessels in
Boundaries the carotid triangle are the common carotid artery and ECA.
The ICA has no branches in the neck.

VI. MUSCULAR TRIANGLE

Boundaries

!
Figure 9. Carotid triangle (dashed lines).

• Bounded by the superior belly of omohyoid,

posterior belly of digastric, and anterior border of
SCM
!
Contents Figure 11. Muscular triangle (dashed lines).
1. Carotid sinus - it is a baroreceptor (presoreceptor) that
reacts to changes in arterial blood preasure. Innervated by • Bounded by the superior belly of the omohyoid muscle,
CN IX (via the carotid sinus nerve) and CN X. the anterior border of the SCM, and the median plane of
the neck
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ANAT 12AB: Anterior Triangle and Root of the Neck Exam #1 - Trans #4

Contents ▪ Posterior - Esophagus

▪ Right side - Brachiocephalic trunk

→ Esophagus
▪ muscular tube that conveys food from the pharynx to
the stomach
▪ 25 cm long
▪ No serosa
▪ Relations:
▪ Anterior - Trachea; tracheoesopharyngeal groove -
recurrent laryngeal nerve
▪ Posterior: Cervical vertebrea and prevertebral
muscles
▪ Left side: Thoracic duct (largest lymphatic duct of
! the body) and cervical pleura
Figure 12. Relationships of thyroid gland. ▪ Right side: Cervical pleura

1. Infrahyoid muscles VII. ROOT OF THE NECK

2. Neck viscera
→ Thyroid gland • junctional area between the thorax and neck
▪ largest endocrine gland • thoracic inlet
▪ right & left lobes joined by isthmus, which is anterior to • located on the cervical side of the superior thoracic aperture
2nd-3rd tracheal rings
▪ superior and inferior lobes Boundaries
▪ pyramidal lobe is the extension from upper part of 1. Inferior: Superior thoracic aperture
isthmus 2. Lateral: First pair of ribs
▪ true capsule (encloses the gland) and false capsule 3. Anterior: Manubrium of the sternum
(pretracheal fascia) 4. Posterior: Body of T1 vertebra
▪ Origin: Foramen caecum
▪ Attachment: Cricoid and thyroid cartilages Contents
▪ Blood supply: superior and inferior thyroid arteries (In
10% of people, a thyroid ima artery may arise from
brachiocephalic trunk)
▪ Venous drainage: Superior thyroid v. and middle
thyroid v. drain into the IJV, while inferior thyroid v. drain
into the brachiocephalic v.
▪ Lymphatic drainage: prelaryngeal lymph nodes drain
into superior deep cervical lymph nodes, while the
pretracheal and paratracheal lymph nodes drain into
inferior deep cervical nodes.
▪ Innervation: cardiac, superior, & inferior thyroid peri-
arterial plexuses
▪ Relationships - Nerves:
▪ Superior laryngeal nerve - has sensory fibers that
detect foreign body in trachea (coughing
mechanism). Damaged nerve can affect !
cricothyroid muscle, resulting to a monotone voice. Figure 13. Root of the neck.
▪ Inferior or recurrent laryngeal nerve - travels to
esophagus. Damaged nerve can result to a hoarse 1. Arteries
voice. → Brachiocephalic trunk
▪ largest branch of the arch of the aorta
→ Parathyroid gland ▪ covered anteriorly by the right sternohyoid and
▪ small flattened oval glands found external to thyroid sternothyroid muscles
capsule ▪ divides into the right common carotid and right
▪ 2 superior (more constant in position) and 2 inferior subclavian arteries posterior to the sternoclavicular
(can have various positions) parathyroid glands (SC) joint.
▪ Blood supply: inferior thyroid a. → Subclavian artery
▪ Venous drainage: thyroid plexus of veins ▪ supplies the upper limbs and also sends branches to
▪ Lymphatic drainage: deep cervical lymph nodes and the neck and brain
paratracheal lymph nodes ▪ right subclavian artery arises from the brachiocephalic
trunk
→ Trachea ▪ left subclavian artery arises from the arch of the aorta
▪ conducts tube for air ▪ Branches:
▪ fibrocartilaginous tube ▪ Vertebral artery
▪ incomplete tracheal rings a. Cervical part - arises from the first part of the
▪ Deficient posteriorly subclavian artery and ascends in the pyra-
▪ 12 cm long midal space formed between the scalene and
▪ Relations: longus muscles
▪ Anterior - Isthmus of thyroid g.
▪ Lateral - Common carotid a.
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b. Vertebral part - passes deeply to course ▪ sensory distribution

through the foramina transversaria of vertebrae
C1–C6.
c. Suboccipital part - courses in a groove on the
posterior arch of the atlas before it enters the
cranial cavity through the foramen magnum
d. Cranial part - supplies branches to the medulla
and spinal cord, parts of the cerebellum, and
the dura of the posterior cranial fossa.
▪ Internal thoracic artery - arises from the
anteroinferior aspect of the subclavian artery and
passes inferomedially into the thorax
▪ Thyrocervical artery - One of its 4 branches is the
inferior thyroid artery, the primary visceral artery of
the neck, supplying the larynx, trachea, esophagus,
and thyroid and parathyroid glands, as well as
adjacent muscles.
▪ Costocervical artery - The trunk passes
posterosuperiorly and divides into the superior inter-
costal and deep cervical arteries, which supply the
first two intercostal spaces and the posterior deep
cervical muscles, respectively.
▪ provides the sole motor supply to their own half of the
diaphragm
→ Sympathetic trunk
▪ three cervical sympathetic ganglia: superior, middle,
and inferior.
▪ The 3 ganglia receive presynaptic fibers conveyed to
the trunk by the superior thoracic spinal nerves and
their associated white rami communicantes, which then
ascend through the sympathetic trunk to the ganglia.
4. Nerves
→ Thoracic duct
▪ largest lymphatic vessel in the body
▪ it drains lymph from both lower limbs, abdomen (not the
convex area of liver), left hemithorax, left upper limb
and left face and neck
→ Right lymphatic duct
▪ union of right jugular, subclavian, and
bronchomediastinal lymphatic trunks
→ Jugular trunk
▪ joins thoracic duct on left side
▪ enters junction of internal jugular and subclavian veins
→ Subclavian trunk
▪ drains right upper limb and superficial regions of
thoracic and upper abdominal wall

VIII. PREVERTEBRAL MUSCLES

!
Figure 14. Nerves and vessels of the neck.

2. Veins
→ Subclavian vein
▪ Continuation of the axillary vein, begins at the lateral
border of the 1st rib and ends when it unites with the !
IJV Figure 15. Prevertebral muscles.
▪ Only tributary: EJV • deep to prevertebral layer of deep cervical fascia.
→ Internal jugular vein • anterior vertebral muscles
▪ collects the blood from the brain, the superficial parts of
the face, and the neck → posterior to the retropharyngeal space
→ medial to the neurovascular plane of the cervical and
→ Brachiocephalic vein
brachial plexuses and subclavian artery.
▪ returns deoxygenated blood from the upper limbs, neck • lateral vertebral muscles
and head to the heart
→ posterior to neurovascular plane
→ Anterior jugular vein
→ forms the floor of the lateral cervical region (except for
▪ usually smallest of the jugular veins
rectus capitis lateralis)
▪ right and left AJVs usually unite across the midline to
form the jugular venous arch in the suprasternal space Muscles
→ External jugular vein
▪ drains blood received mostly from the scalp and face Table 3. List of anterior vertebral
muscles.
3. Nerves
→ Vagus nerve (CN X) Superior Inferior
Muscles Innervation Action
▪ between common carotid artery and internal jugular Attachment Attachment
vein Anterior
→ Recurrent laryngeal nerve tubercle of
▪ arises from the vagus nerves in the inferior part of the Bodies of Flexes neck
C1 vertebra
neck C5–T3 Anterior with rotation
(atlas);
vertebrae; rami of (torsion) to
▪ right recurrent laryngeal nerve loops inferior to the right Longus bodies of
transverse C2–C6 opposite
subclavian artery at approximately the T1–T2 vertebral colli C1–C3 and
processes spinal side if acting
level transverse
of C3–C5 nerves unilaterally
▪ left recurrent laryngeal nerve loops inferior to the arch processes
vertebrae
of C3–C6
of the aorta at approximately the T4–T5 vertebral level.
vertebrae
→ Phrenic nerve

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ANAT 12AB: Anterior Triangle and Root of the Neck Exam #1 - Trans #4

Anterior Anterior
Basilar part tubercles of rami of
Longus of occipital C3–C6 C1–C3 REFERENCES
capitis bone transverse spinal • Dr. Villacorta’s lecture slides
processes nerves • Moore’s Clinically Oriented Anatomy 7th ed.
Branches
• Batch 2021 trans
Base of Anterior from loop
Rectus cranium, surface of between Flex head
capitis just anterior lateral mass END OF TRANS
C1 and C2
anterior to occipital of atlas (C1 spinal
condyle vertebra) nerves

Transverse Cervical
Anterior processes spinal
1st rib
scalene of C3–C6 nerves
vertebrae C4–C6

Table 4. List of lateral vertebral

muscles.
!
Superior Inferior
Muscles Innervation Action
Attachment Attachment

Branches
Flexes
Jugular Transverse from loop
Rectus head and
process of process of between C1
capitis helps
occipital atlas (C1 and C2
lateralis stabilize it
bone vertebra) spinal
nerves

Laterally
flexes and
Inferior half rotates
Lateral
of nuchal Posterior head and
aspect of
ligament and rami of neck to
mastoid
Splenius spinous middle same
process and
capitis processes of cervical side;
lateral third
superior six spinal acting
of superior
thoracic nerves bilaterally,
nuchal line
vertebrae extends
head and
neck

Downwar
d rotation
Dorsal
Posterior of scapula
scapular
tubercles of Superior part and tilts
nerve C5
Levator transverse of medial its glenoid
and cervical
scapulae processes border of cavity
spinal
C2–C6 scapula inferiorly
nerves C3
vertebrae by
and C4 rotating
scapula

Flexes
Superior neck
surface of Anterior laterally;
1st rib; rami of
Middle elevates
posterior to cervical
scalene 1st rib
groove for spinal during
Posterior sub- clavian nerves forced
tubercles of artery inspiration
transverse
processes of Flexes
C5–C7 Anterior neck
vertebrae rami of laterally;
External
Posterior cervical elevates
border of
scalene spinal 2nd rib
2nd rib nerves C7 during
and C8 forced
inspiration

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