ACD 3: NECK ○ I: Body of mandible

NECK
○ N: Facial nerve
○ A: Depresses mandible
● Lies between the lower margin of the
● ☞ Clinical importance:
mandible above, the suprasternal notch, and
○ Can be seen as a thin sheet of muscle
upper border of clavicle below
just beneath the skin by clenching
● Extensor muscles lies posterior to the
one’s jaws firmly
vertebrae
○ Lacerations or surgical incisions:
● Smaller group of flexor muscles sits anteriorly
■ Subcutaneous layer with the
● ANTERIOR region of the neck: parts of the
platysma should be carefully
respiratory system (larynx and trachea)
sutured
● POSTERIOR region of the neck: parts of the
■ Tone of platysma can pull on
alimentary system (pharynx and esophagus)
the scar tissue
● At the sides: carotid arteries, internal jugular
○ Platysma innervation and mouth
veins, vagus nerve, deep cervical lymph
distortion:
nodes
■ Cervical branch of the facial
★ Cervical part of vertebral column
nerve innervates platysma
● Convex forward
■ Nerve emerges from lower
● Supports the skull
end of parotid gland
● Forms bony longitudinal axis of neck
■ Traveling forward to platysma
★ Hyoid bone
■ !! sometimes, crosses the
● Moves relatively freely
lower border of the mandible
● Anchors the tongue
to supply depressor anguli oris
★ Skin and superficial fascia
muscle
● Natural lines of the cleavage of the skin are
■ Skin lacerations over mandible
constant and run horizontally around the neck
or upper part of neck that
● ☞ Clinical importance:
affect the platysma → distort
○ Incision along a cleavage line → heals
shape of mouth
as a narrow scar
■ (note: insertion of the platysma
○ Incision across the lines → heals as a
is also at the angle of the
wide or heaped-up scar
mouth)
● Superficial fascia
○ Thin layer that encloses the cutaneous CUTANEOUS NERVES
nerves, platysma muscle, superficial ★ The posterior rami of cervical nerves 2 to 5 supply
veins, superficial lymph nodes the skin overlying the trapezius muscle on the back of
the neck and the back of the scalp as high as the
vertex
STRUCTURES FOUND IN SUPERFICIAL FASCIA OF
● Greater occipital nerve: branch of the
NECK
posterior ramus of second cervical nerve
PLATYSMA ★ Cervical plexus: supplies the skin on the front and
● Thin, broad, muscular sheet embedded in the sides of the neck (specifically, anterior rami of CN 2-4)
superficial fascia ● Lesser occipital nerve (C2)
● One of the facial muscles derived from the ○ Hooks around accessory nerve
first pharyngeal arch ○ Ascends along posterior border of the
● Innervated by facial nerve SCM
● OINA: ○ Supply the skin over the lateral part of
○ O: Deep fascia over pectoralis muscle the occipital region and medial surface
 of auricle ● Superior to the sternocleidomastoid
● Great auricular nerve (C2, C3)
○ Ascends across SCM
○ Supply skin over mandible, parotid
gland, both surfaces of auricle
● Transverse cutaneous nerve (C2, C3)
○ Emerges from behind the posterior
border of SCM
○ Passes forward across the muscle
○ Supplies the skin on anterior and
lateral surfaces of the neck
■ Body of mandible to sternum
● Supraclavicular nerve (C3, C4)
○ Emerges from behind the posterior
border of SCM
● Extends from the angle of the mandible to the
○ Descends across side of neck
middle of clavicle
○ Branches:
● Tributaries:
■ Medial: supplies skin of medial
○ Posterior auricular vein
plane
○ Posterior division of the
■ Intermediate: supplies skin of
retromandibular vein
chest wall
○ Posterior external jugular vein
■ Lateral: supplies skin over
■ Drains posterior part of scalp
shoulder as far down the spine
and neck
of scapula
○ Transverse cervical vein
○ Suprascapular vein
○ Anterior jugular vein
■ Veins of 2 sides unite by a
transverse trunk: jugular arch
■ Drains into the external jugular
vein
● ☞ Clinical importance:
○ Less obvious in children and women
(subcutaneous tissue is thicker)
○ Serves as a useful venous manometer
○ Can be used for catheterization
■ Right external jugular vein:
most direct line with the
superior vena cava
★ Superficial lymph nodes
● Lie along external jugular vein
● Receive lymph vessels from the occipital and
mastoid lymph nodes
EXTERNAL JUGULAR VEIN
● Drain into the deep cervical lymph nodes
● Begins just behind the angle of the mandible
● Union of posterior auricular vein and posterior
portion of the retromandibular vein
 NECK MUSCLES STERNOCLEIDOMASTOID
Strap muscles ● Divides the neck into anterior and posterior
Sternocleidomastoid triangles
+ muscles anterior to it ● Anterior border:
+ inferior belly of the omohyoid ○ Covers the carotid arteries, internal
● Suprahyoid muscles jugular vein, deep cervical lymph
○ Superior to the hyoid bone nodes
○ Anterior and posterior bellies of the ○ Overlaps the thyroid gland
digastric muscle ● Skin, fascia, platysma muscle, and external
○ Mylohyoid jugular vein cover the muscle superficially
○ Geniohyoid (superior to the ● Deep surface of the posterior border is related
mylohyoid) to the cervical plexus of nerves, phrenic
○ Genioglossus nerve, upper part of brachial plexus
○ Stylohyoid (small strip near the ● ☞ Clinical importance:
posterior digastric) ○ SCM is a strong thick muscle that
● Infrahyoid muscles crosses the side of the neck
○ Inferior to the hyoid bone ■ Protects underlying soft
○ Omohyoid structures from blunt trauma
○ Sternohyoid ○ Suicide attemps by cutting throats
○ Sternothyroid often fail because the individual first
○ Thyrohyoid extends the neck before making cuts
■ Only infrahyoid muscle NOT ■ Extension of the cervical part
innervated by Ansa Cervicalis; of vertebral column +
it is innervated by C1 via extension of the head at the
hypoglossal nerve atlanto-occipital joint → carotid
● Deep neck muscles sheath to slide posteriorly
○ Scalenus anterior beneath the SCM
○ Scalenus medius ■ To achieve suicide with the
○ Scalenus posterior head fully extended, several
○ Longus colli cuts have to be made
○ Longus capitis ■ Common sites for wounds:
above and below hyoid bone
○ Congenital torticollis in infants:
■ Result from excessive
stretching of the SCM during
difficult labor → shortened
SCM
■ Hemorrhage occurs in the
muscle → invaded by fibrous
tissue which contracts and
shortens the muscle
○ Spasmodic torticollis:
■ Results from repeated chronic
contractions of the SCM and
trapezius muscles
 ANTERIOR TRIANGLE OF NECK ● Anterior jugular vein
● Boundaries: sternocleidomastoid, midline of ○ Submandibular triangle:
neck, lower margin of body of mandible ■ Borders:
● Lower margin of the
body of mandible
● Anterior belly of
digastric
● Posterior belly of
digastric
■ Contents:
● Submandibular gland

● Subdivisions:
○ Muscular triangle
■ Borders:
● Anterior midline
● Anterior edge of SCM
● Superior belly of
omohyoid
■ Contents:
● infrahyoid muscles
● Thyroid gland
● Parathyroid gland
○ Carotid triangle:
■ Borders:
● Superior belly of
omohyoid
● Anterior edge of SCM
● Posterior belly of
digastric
■ Contents:
● Common carotid artery
● Carotid sinus
● Carotid body DEEP CERVICAL FASCIA
○ Submental triangle: ● Supports the muscles, vessels, and viscera of
■ Borders: the neck
● Anterior midline ● In certain areas, it is condensed to form
● Hyoid bone well-defined fibrous sheets
● Anterior belly of ● Prevents spread of infection to deeper layers
digastric ● Separates different structures of the neck
■ Contents: ○ To gauge depth of incision made
● Submental lymph during surgery
nodes
★ Investing layer (Investing Deep Fascia) ● Will likely spread to
● Superficial layer anterior thorax
● Thick layer that encircles the neck ■ Within retropharyngeal space
● Splits the trapezius and SCM ● Swelling will affect
★ Pretracheal layer (Pretracheal fascia; thyroid swallowing & speech
capsule) → further swelling
● Thin layer affects airway
● Attached above to the laryngeal cartilages ● May spread to thorax
● Surrounds the thyroid and parathyroid glands, ● Infections:
forming a sheath ○ Acute infection
● Encloses the infrahyoid muscles ■ Dental infections
★ Prevertebral layer (Prevertebral fascia) ● Commonly involve
● Deepest layer lower molar teeth
● Thick layer which forms the fascial floor of the ● Spreads from
posterior triangle mandible →
● Extends laterally over the the first rib into submandibular →
axilla to form the important axillary sheath masticatory spaces =
● Axillary sheath: pushes tongue forward
○ Encloses subclavian artery and and upward
brachial plexus ● Further spread
☞ Carotid sheath: downward = edema in
● Local condensation of the pretracheal, vocal cords and airway
prevertebral, and investing layers of the deep obstruction
fascia ■ Ludwig angina
● Contents: ● Infected
○ Common carotid artery submandibular fascial
○ Internal carotid artery space
○ Internal jugular vein ○ Chronic infection
○ Vagus nerve ■ Tuberculous infection of deep
○ Deep cervical lymph nodes cervical lymph nodes
☞ Clinical significance:
● Cervical fascia (layers of the neck):
○ Surgical orientation
○ Understanding spread of disease
● Facial spaces
○ Between denser layers of deep fascia,
loose connective tissue forms
potential spaces that are clinically
important
○ Infections:
■ Between investing and
muscular pretracheal
● Typically stops at
manubrium
■ Between investing and
visceral pretracheal
 becomes axillary artery
● Left subclavian artery
○ Arises from arch of the aorta in thorax
○ Scalenus anterior muscle passes
anterior to the artery on each side and
divides it into 3 parts
★ Subclavian vein
● Commencement: outer border of first rib as a
continuation of the axillary vein
● Subclavian vein + Internal jugular vein →
brachiocephalic vein
★ Thoracic duct
● Begins in the abdomen at upper end of
cisterna chyli
HEAD AND NECK ARTERIES
● Two arterial tracts supply blood to the head
and neck
○ Carotid system
■ Supplies blood to the upper
neck and head
○ Subclavian system
■ Supplies lower neck, deep
neck, inside of cranium,
shoulder, upper limb, thorax
CAROTID SYSTEM
★ Common Carotid System
● Termination: superior border of thyroid
cartilage
● Branches: ECA and ICA
● Pulsations: at bifurcation on the level of the
superior border of the thyroid cartilage
● Runs upward through the neck within the
carotid sheath
ROOT OF THE NECK ● Carotid sheath:
● Immediately above the inlet of the neck into ○ I see 10CC in the IV
the thorax ○ “I see” = internal carotid artery
● The scalenus anterior muscle is a key ○ 10 = CN X; Vagus nerve
structure to understanding the root of the neck ○ CC = common carotid artery
● Notable structures: ○ IV = internal jugular vein
○ Subclavian blood vessels ● Right common carotid artery
○ Thoracic duct ○ Origin: Brachiocephalic artery
★ Subclavian artery ○ Commencement: Posterior to the right
● Right subclavian artery sternoclavicular jont
○ Arises from brachiocephalic artery ● Left common carotid artery
○ At the outer border of the first rib, ○ Origin: arch of aorta
○ Commencement: Superior
 mediastinum
● Divides into the External and Internal carotid
artery at the carotid triangle of the neck
★ External Carotid Artery (ECA)
● Origin: common carotid artery
● Commencement: superior border of thyroid
cartilage
● Termination: substance of the parotid gland
posterior to neck of mandible
● Branches
○ Terminal branches:
■ Maxillary artery
● Larger terminal branch
of ECA
● Supplies upper and
lower jaws, muscles of
mastication, meninges
of skull
● Branch: middle
meningeal artery
○ Grooves
across pterion
○ Prone to
damage after a
blow to the
head
■ Superficial temporal artery
● Smaller terminal
branch of ECA
● Palpated in front of
auricle
● Accompanies
auriculotemporal nerve
● Supplies scalp
○ Other branches of ECA:
■ Superior thyroid artery
● Supplies thyroid gland
■ Ascending pharyngeal artery
● Supplies pharyngeal
wall
■ Lingual artery
● Supplies tongue
■ Facial artery
● Supply tonsil,
submandibular salivary
gland, muscles and
skin of face
■ Occipital artery
● Supplies back of scalp
■ Posterior auricular artery
● Supplies auricle and
scalp
★ Internal Carotid Artery
● Origin: CCA
● Commencement: Superior border of thyroid
cartilage
● Termination: divides into anterior and middle
cerebral arteries
● Ascends into cranium
○ Ophthalmic artery → branches into
supratrochlear + supraorbital arteries
● Supplies brain, eye, forehead, some parts of
nose
☞ Clinical significance:
● ICA arteriosclerosis
○ Through retinal artery: can cause
visual impairment or blindness in the
eye on the side of lesion
○ Through middle cerebral artery: motor
paralysis and sensory loss
★ Carotid sinus
● Localized dilation at internal carotid artery
● Reflex area of carotid (reflex pressoreceptor)
● Contains numerous nerve endings from
glossopharyngeal nerve
 ● Baroregulator (regulates blood pressure) ● Pharyngeal veins
○ Reacts to a rise in blood pressure ● Lingual vein
○ Response: slows heart rate and ● Superior thyroid vein
vasodilation of the arterioles ● Middle thyroid vein
☞ Clinical significance:
● Carotid massage
○ Used for arrhythmia or tachycardia
that results in pressure abnormalities
○ Slows down heart rate
○ Temporizes tachycardia of patient
● Carotid Sinus Hypersensitivity or Syndrome
○ External pressure on one or both
carotid sinus (from extension of neck)
→ can cause excessive slowing of the
heart rate, fall in blood pressure,
cerebral ischemia w/ fainting
(syncope)
★ Carotid body
● A small body located at bifurcation of external
and internal carotid arteries
● Innervated by glossopharyngeal nerve
● Chemoreceptor
○ Affected by excess in
hemoconcentration of O2 and CO2,
pH & temperature
○ Response: rise in blood pressure and
heart rate and increase in respiratory
rate NERVE SYSTEM
INTERNAL JUGULAR VEIN HYPOGLOSSAL NERVE CN XII
★ Formation/course: ● Motor nerve composed of motor fibers (purely
● Begins with sigmoid sinuses motor)
● Exits through the jugular foramen ● Course:
● Descends through the neck in the carotid ○ Emerges on the anterior surface of
sheath (with CCA, Vagus nerve, Internal medulla oblongata
Carotid Artery) ○ Crosses posterior cranial fossa
● Ends by joining the subclavian vein behind ○ Exits hypoglossal canal
medial end of clavicle to form brachiocephalic ○ Passes downward and forward in the
vein neck and crosses the ICA and ECA to
● Closely related to deep cervical lymph nodes reach the tongue
★ Commencement and termination ■ Innervates muscles of the
● Commencement: Tip of mastoid process and tongue (except palatoglossus)
angle of jaw ■ Controls shape and
● Termination: sternoclavicular joint movements of tongue
★ Tributaries ○ Upper part of its course
● Inferior petrosal sinus ■ C1 fibers from cervical plexus
● Facial vein joins
● Branches
○ Meningeal branch
○ Descending branch (C1 fibers)
■ Passes downwards
■ Joins the descending cervical
nerves (C2, C2) to form ansa
cervicalis
■ Supples omohyoid,
sternohyoid, sternothyroid
○ Nerve to the thyrohyoid muscle and
geniohyoid (C1)
■ Only infrahyoid muscle NOT
innervated by ansa cervicalis
■ Only suprahyoid muscle NOT
innervated by ansa cervicalis
○ Muscular branches to all the muscles
of tongue except palatoglossus
VAGUS NERVE CN X
● Composed of motor and sensory fibers
● Most extensive distribution of all cranial
nerves
● Course:
○ Emerges from anterior surface of
medulla oblongata between olive and
inferior cerebellar peduncle
○ Passes laterally through the posterior
cranial fossa
○ Leaves skull through jugular foramen
■ Along with accessory nerve
and glossopharyngeal nerve
○ Descends along with carotid sheath
○ Passes through mediastinum of thorax
→ behind root of lung
○ Enters abdomen through esophageal
opening in diaphragm
● Has both superior and inferior sensory ganglia
○ Below inferior ganglion
■ Cranial root of accessory
nerve joins vagus nerve →
pharyngeal and recurrent
laryngeal branches
● Important branches
○ Auricular branch
■ Supplies pinna, external
auditory meatus, tympanic
membrane
○ Pharyngeal branch
■ Contains nerve fibers from
cranial part of accessory nerve
■ Joins pharyngeal plexus
■ Supplies muscles of pharynx
and soft palate
○ Superior laryngeal nerve
■ Divides into internal and
external laryngeal nerves
■ Internal laryngeal nerve
● Sensory to mucous
membrane of the
piriform fossa and
larynx down to vocal
cords
■ External laryngeal nerve
● Motor
● Located close to
superior thyroid artery
● Supplies cricothyroid
muscle
○ Recurrent laryngeal nerve
■ Closely related to inferior
thyroid artery
■ Supplies all muscles of larynx
 (except cricothyroid muscle),
mucous membrane of larynx
and upper part of trachea
■ Right recurrent laryngeal
nerve
● Hooks around
subclavian artery
■ Left recurrent laryngeal nerve
● Hooks around arch of
aorta
THYROID GLAND
○ Cardiac branches
● Consists of pear shaped right and left lobes
■ Arise in neck ● Narrow isthmus lies between 2nd to 4th
■ Descend into thorax tracheal ring
■ End in cardiac plexus ● Superior pole of thyroid gland
SUBMANDIBULAR GLAND
○ Reaches until the lamina of the thyroid
cartilage
● Found in the submandibular triangle of the ● Inferior pole of thyroid gland
neck ○ Reaches as low as 4th and 5th
○ Also known as the digastric triangle tracheal ring
● Divided into superficial and deep part by the ● Neurovascular supply
Mylohyoid muscle ○ Arterial supply:
○ Superficial ■ Superior thyroid artery
■ Beneath the lower margin of ● Originates from ECA
the body of the mandible ● Associated with
○ Deep external laryngeal
■ Palpated through mucous artery
membrane covering the floor ■ Inferior thyroid artery
of the mouth in the interval ● Originates from
between tongue and lower jaw subclavian artery
■ Can also palpate ● Associated with
submandibular duct & recurrent laryngeal
sublingual gland artery
■ Submandibular duct ○ Nerve supply
● Opens into mouth on ■ Superior, middle, inferior
the side of the cervical sympathetic ganglia
frenulum of the tongue ○ Venous drainage
● Neurovascular supply ■ Superior thyroid vein & middle
○ Arterial supply thyroid vein
■ Submental arteries ● Drains into IJV
○ Nerve supply ■ Inferior thyroid vein
■ Facial nerve ● Drains into left and
● Via chorda tympani right brachiocephalic
and submandibular vein
ganglion ○ Lymph drainage
○ Venous drainage ■ Deep cervical lymph nodes
■ Submental veins
○ Lymph drainage
■ Deep cervical lymph nodes
☞ Clinical significance:
● Common site of calculus formation
● Acute infection of the teeth

● Functions of Thyroid gland
○ Thyroid hormones
■ Thyroxine
■ Triiodothyronine
■ Increase metabolic activity
○ Parafollicular cells
■ Produce thyrocalcitonin
■ Lowers level of blood calcium
☞ Clinical significance:
☞ Clinical significance:
● Invested in a sheath derived from pretracheal
fascia
○ Tethers gland to larynx and trachea
○ Follows movements of the larynx in
swallowing
● Retrosternal goiter
PARATHYROID GLAND
● Ovoid bodies 6mm long (greatest diameter)
● 4 in number
○ 2 superior
■ More constant in position
■ Level of the middle of the
posterior border of thyroid
gland
○ 2 inferior
■ Close to inferior pole of thyroid
gland
■ May lie within fascial sheath,
embedded, or outside fascial
sheath
● Closely related to posterior border of thyroid
gland, lying within its fascial capsule
● Neurovascular supply
○ Arterial supply
■ Superior and inferior thyroid
arteries
○ Nerve supply
■ Superior and middle cervical
sympathetic ganglia
○ Venous drainage
■ Superior thyroid vein
■ Middle thyroid vein
■ Inferior thyroid vein
○ Lymph drainage
■ Deep cervical lymph nodes
● Functions:
○ Parathyroid hormone
■ Stimulates osteoclastic activity
■ Mobilizing bone calcium
■ Increasing calcium levels in
blood
● Partial thyroidectomy
○ Posterior part of the thyroid gland is
left undisturbed so that the parathyroid
glands are not damaged