Far Eastern University – Nicanor Reyes Medical Foundation B.

POSTERIOR (LATERAL) TRIANGLE

Gross B – Superficial Structures & Post. Cervical Triangle of the Neck  Contains the neuromuscular structures
Clester Bea, M.D. (add. notes from James Taclin Banez, M.D.)  Accessory spinal nerve
 Lateral muscles of the neck
NECK  Boundaries
 Connects the head and the thorax, made up of skeletal muscles  Anteriorly: Sternocleidomastoid
 At the back, it is represented at the midline by the cervical  Posterolaterally: Trapezius
vertebra which is covered on both sides by the trapezius muscle  Inferiorly: Clavicle

The natural lines of cleavage of the skin are constant and run almost Trauma to the central triangle is more fatal compared to trauma in the
horizontally around the neck. This is important clinically because an lateral triangle of the neck. Trauma to the central triangle can block the
incision along a cleavage line will heal as a narrow scar, whereas one blood supply to the head and block the airway for breathing. Trauma to
that crosses the lines will heal as a wide or heaped-up scar. the lateral triangle can paralyze the muscles of the neck.

Boundaries of the Neck: Surface Landmark:

 Superior (anterior):  Laryngeal Prominence
 Lower margin of the mandible and Superior nuchal line of  Known as the Adam’s Apple in males
the cranium  Formed by the thyroid (tracheal) cartilage
 Inferior:  Sternocleidomastoid
 Suprasternal notch and the upper border of the clavicle  Two points of origin: manubrium (head of the sternum) and
 Anterior: the clavicle
 Anterior midline of the neck  Inserted to the mastoid process of the temporal bone
 Posterior:
 Trapezius COMPARTMENTS OF THE NECK
 The subcutaneous tissue and superficial fascia is found
In surgery, the clavicle and the manubrial notch are used to divide the
immediately beneath the skin of the neck supporting the
thoracic cavity and the cervical region. Anything below is the thoracic
platysma muscle, neurovascular structures and lymph nodes
region, anything above is the cervical region
 Deep the superficial fascia is formed by the deep cervical fascia
which makes the area of the neck limited
Triangles of the Neck:
 The two triangles are separated by the sternocleidomastoid A. DEEP CERVICAL FASCIA
 Embraces muscles and visceral structures anteriorly
 Condensed to form well defined, fibrous sheets

A. ANTERIOR (CENTRAL) TRIANGLE

 Contains the visceral structures
 Trachea
 Larynx
 Esophagus
1. Superficial (Investing) Fascia
 Carotid Sheath and contents
 Most superficial of the deep cervical fascia and goes all the
 Boundaries
way around the neck
 Superiorly: Inferior border of the mandible
 Splits into two to cover the the sternocleidomastoid and
 Laterally: Medial border of the sternocleidomastoid
trapezius
 Medially: Imaginary sagittal line, midline
 Suprasternal Space of Burns – space formed by the
superficial fascia near the manubrium. This is where the

Page 1 of 6
 jugular arch, a branch of the anterior jugular vein passes
through
 Serves as the roof of the posterior triangle of the neck
 Superior attachment: hyoid bone, lower border of the
mandible, zygomatic arch and occipital bone
 Inferior (anterior) attachment: acromion, clavicle,
manubrium
 Posterior attachment: spinous process of cervical vertebrae
and ligamentum nuchae. Holds the omohyoid to the clavicle
2. Pretracheal Fascia
 Middle fibrous sheet from the deep cervical fascia
 Attachment: superiorly to the oblique line of thyroid
cartilage and cricoid cartilage, inferiorly to the sternum
 Continues to the mediastinum to blend with the pericardium
 Muscular part ensheaths the strap muscles (sternohyoid,
sternothyroid, omohyoid)
 Visceral part ensheaths the side of esophagus, larynx,
trachea, thyroid and parathyroid
 Acts as pseudocapsule of the thyroid
3. Prevertebral Fascia
 Deepest layer and starts at the posterior midline
 Attachment: Base of skull. Enters the thorax and blends with
the anterior longitudinal spinous process and ligamentum
nuchae
 Encloses lateral vertebral muscles and prevertebral muscles
 Muscles of the back: splenius capitis, semispinalis capitis
and iliocostalis capitis
 Suboccipital muscles: rectus capitis posterior major and
minor, oblique capitis superior and inferior
 Forms the floor of the posterior triangle of the neck and
covers the body of the vertebra
 Extends laterally to the first rib, into the axilla to form the
axillary sheath
1.
4. Carotid Sheath
 Tubular condensation of the layers of the deep cervical fascia
 Blends with the superficial, pretracheal fascia and
prevertebral fascia (union of the three fasciae)
 From the base of the skull to the root of the neck
 Contents:
 Common and internal carotid arteries – most medial
 Internal Jugular Vein – most lateral
Page 2 of 6
 Vagus nerve – most posterior, located between the
carotids and internal jugular vein
 Deep cervical lymph nodes
 Root of ansa cervicalis - supplies the strap muscles
(deep muscles of the neck)
The common carotid has no branch except at the level of the superior
horn of the tracheal cartilage. This is where it will divide into the
external and internal carotid artery. The internal carotid artery is within
the carotid sheath, but does not give off any branch until it reaches the
cranial nerve
5. Retropharyngeal Sheath / Space
 Potential space between the pharynx and the prevertebral
fascia
 Danger space of the neck because this may serve as a
possible route for spread of infection from head to
mediastinum
 Alar fascia
 Subdivision of the retropharyngeal space
 Attached along the midline of Buccopharyngeal fascia
from cranium to C7
 Terminates to the carotid sheath
 Anterior border: pretracheal fascia
 Posterior border: prevertebral fascia
When a patient has pharyngitis and left untreated the infection may go
into the retropharyngeal space. The abscess may then continue to
spread to the mediastinum thereby causing medisatinitis.
6. Axillary Sheath
 Extension of the prevertebral fascia, carried to the axilla by
the subclavian artery and the brachial plexus
 Formed as C5-T1 forms the brachial plexus
 Encloses the axillary vessels and the brachial plexus
B. SUPERFICIAL CERVICAL FASCIA
 Forms a thin layer that encloses the platysma muscle
 Embedded on it are the cutaneous nerves, superficial veins
(external and anterior jugular) and superficial lymph nodes
Platysma – anterolateral structure, superficial muscle of the neck
Origin: Fascia of the deltoid and pectoralis major
Insertion: Skin and the superficial fascia of the lower face,
angle of the mouth
Action: Draws lower lip downward and back. Considered as
muscle of facial expression
Nerve: Cervical branch of the Facial Nerve
Platysma = superficial muscles of the neck
Strap muscles = deep muscles of the neck
 3. Anterior Jugular Vein

Jugular Arch

 Lies in the sternohyoid and begins below the chin, near the
hyoid bone from the confluence of the superficial mandibular
veins
In surgery, the platysma muscle serves as a marker in injuries regarding  Formed by superficial veins of the submental area and also a
the neck. An injury penetrating the platysma is considered as a deep contribution from the external jugular vein through the
injury. transverse cervical vein
 May terminate to the external jugular vein or the subclavian
vein
2. External Jugular Vein
 Tributaries:
 Laryngeal vein
 Small thyroid vein
 Jugular arch

The right and left anterior jugular vein lies on the sternohyoid muscle.
The two veins will be connected by one of its tributaries, the jugular
arch. The jugular arch is particularly of importance to the thoracic
surgeons, especially when performing a midline sternal incision.

4. Superficial Lymph Nodes

Superficial Parotid
Nodes

Submandibular
 Most superficial of the jugular veins, begins behind the angle of
Nodes
the mandible and lies in the SCM Superficial Cervical
 Formed by the union of the posterior auricular vein and the Submental
Nodes
posterior division of the retromandibular vein Nodes
Deep Cervical
 Drains mainly into the subclavian vein, but may drain to the
Nodes
internal jugular vein
 Tributaries:
 Transverse Cervical
 Suprascapular
 Anterior Jugular
 Posterior External Jugular – small vein that drains the
 Lies along the external jugular vein superficial to the
posterior part of the scalp and neck and joins the external
sternocleidomastoid
jugular vein about halfway along its course
 Based on anatomy, theses nodes are grouped based on location:
 Posterior Auricular
 Parotid
 Posterior Division of the Retromandibular vein
 Submental
 Submandibular
 Superficial cervical

Page 3 of 6
  Deep cervical Boundaries of the Posterior Triangle of the Neck:
 Receives lymph vessels from the occipital and mastoid lymph  Anteriorly: Sternocleidomastoid
nodes  Posterolaterally: Trapezius
 Drains into deep cervical lymph nodes  Inferiorly: Clavicle

5.Cutaneous Branches of the Cervical Plexus Divisions of the Posterior Triangle of the Neck:
 Purely sensory  Occipital Triangle
 These nerves are part of the cervical plexus (C1-C4, minimal  Contains the lateral muscles of the neck
from C5)  Apex contains portion of the occipital bone and occipital
 Lesser Occipital artery
 Anterior rami of C2  Crossed by the accessory nerve
 Supplies the skin over the lateral part of the occipital  Supraclavicular or Subclavian Triangle
region and the medial surface of the auricle  Contains brachial plexus and subclavian vessels
 Great Auricular  Crossed by the external jugular vein and subclavian artery
 Anterior rami of C2-C3
 Supplies the skin over the angle of the mandible, the
parotid gland and on both surfaces of the auricle
 Transverse Cervical (transverse cutaneous)
 Anterior rami of C2-C3
 The skin on the anterior and lateral surfaces of the neck,
from the body of the mandible to the sternum
 Supraclavicular
 Anterior rami of C3-C4
 Medial part crosses the middle end of the clavicle and
supplies the skin as far as the median plain
 Intermediate part crosses the middle of the clavicle and
supplies the skin of the chest wall The inferior belly of the omohyoid serves as boundary between the
 Lateral part crosses the lateral end of the clavicle and two triangles
supplies the skin over the shoulder and upper half of the
deltoid muscle
 Supplies the posterior aspect of the shoulder down to Floor of the Posterior Triangle:
the spine of the scapula  Semispinalis capitis
 The lesser occipital nerve and great auricular nerve supply the  Splenius capitis
back of the ear  Levator scapula
 First Cervical nerve  Posterior scalene
 Has no cutaneous innervation  Scalene medius
 Greater Occipital nerve  Scalene anterior
 Branch of the posterior rami of the 2 cervical nerve
nd

POSTERIOR TRIANGLE OF THE NECK

The brachial plexus will be seen emerging between the anterior and
middle scalene to supply the upper extremities

Page 4 of 6
1. Semispinalis capitis Arteries in the Posterior Triangle of the Neck
Origin: Transverse process of T1-T6  Transverse cervical artery – branch of the thyrocervical trunk
Insertion: Occipital bone between superior and inferior  Suprascapular artery – branch of the thyrocervical trunk
nuchal line  Third part of the subclavian artery – usual location of aneurysm
Action: Extend the head (both); rotate the head to the because it is compressed by the clavicle and the first rib
side (individually)  Occipital artery – branch of the external carotid artery
Nerve: Dorsal rami of the cervical nerve

2. Splenius capitis
Origin: Ligamentum nuchae and spinous process of C7-
T4
Insertion: Lateral superior nuchal line near the mastoid
process
Action: Extend the head and neck (both); rotate head
same side (individually)
Nerve: Dorsal rami of the lower cervical nerve

3. Levator scapula
Origin: Transverse process of C1-C4
Subclavian Artery – divided into three parts by the anterior scalene
Insertion: Upper medial border of the scapula
Action: Elevates the scapula
1. First Part – medial border of anterior scalene
Nerve: Dorsal scapular nerve (C3-C5)
a. Vertebral artery
 Basilar artery
The accessory nerve has nuclei in the medulla oblongata and in the
b. Thyrocervical trunk
cervical region. It lies on the levator scapula
 Inferior thyroid artery
 Suprascapular artery
4. Scalene posterior
 Transverse cervical artery
Origin: Transverse process of C4-C6
c. Internal thoracic artery
Insertion: 2nd rib
 Superior epigastric artery
Action: Elevates the 2nd rib and assists in forceful
inspiration  Musculophrenic artery
Nerve: C6-C8 2. Second part – behind anterior scalene
a. Costocervical trunk
5. Scalene medius  Superior intercostals artery
Origin: Transverse process of C1-C7  Deep cervical artery
Insertion: 1st rib 3. Third part – lateral border of anterior scalene
Action:
st
Elevates the 1 rib, flexes and rotates cervical  No branch, but superficial cervical, dorsal scapular and
vertebra suprascapular arteries may arise here
Nerve: C3-C7
Nerves in the Posterior Triangle of the Neck
6. Scalene anterior 1. Accessory nerve

Origin: Transverse process of C3-C6

st
Insertion: 1 rib (scalene tubercle)
st
Action: Elevates 1 rib, slight rotation of neck
Nerve: Lower cervical nerves (C4-C6)

Veins in the Posterior Triangle of the Neck

 External Jugular vein and tributaries
 Subclavian vein
 Continuation of axillary vein and receives the external
jugular vein
 Receives thoracic duct and the right lymphatic duct
 Passes the levator scapula accompanied by the anterior rami of
 With the internal jugular vein, it forms the brachiocephalic
C3-C4
vein
 Innervates the trapezius and sternocleidomastoid

Page 5 of 6
2. Cervical plexus  Roots emerge between the anterior and middle scalene
 Supraclavicular part is found in the posterior triangle,
infraclavicular part in the axilla
 Branches from the roots:
 Dorsal scapular nerve (C5) – supplies the levator scapula and
rhomboid muscles
 Long thoracic nerve (C5-C7) – supplies the serratus anterior
 Nerve to longus coli and scalene muscles (C5-C8)
 Branches from the upper trunk:
 Suprascapular nerve – supplies the supraspinatus and
infraspinatus muscles
 Nerve to subclavius – supplies the subclavius

The middle trunk, inferior trunk and the divisions of the brachial plexus
are not seen on the posterior triangle of the neck.
 Found between the anterior and middle scalene, and deep to
the sternocleidomastoid and goes to the axilla.
 Roots of the lower cervical plexus joins the brachial plexus to
supply the upper extremities
 The superficial branches of the plexus that initially pass
posteriorly are sensory branches. The deep branches passing
anteromedially are motor branches.
 Phrenic nerve
 Motor nerve of the diaphragm
 Anterior rami of C3-C5. Chiefly from C4
 Lies on the lateral border of anterior scalene
 Cutaneous branches
 Lesser occipital nerve
 Great auricular nerve
 Transverse cervical nerve
 Supraclavicular nerve

3. Brachial plexus

 Anterior rami of C5-T1

 As the plexus divides further, it is classified as: Roots, trunks,
divisions and cords:
 Roots and trunks are found in the cervical region
Sesir rhaenal kipagon moris!
 Divisions are found behind the clavicle
“And so, we begin the journey to the finals!”
 Cords are found below the clavicle, at the level of the axilla

Page 6 of 6