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ANA: ANATOMY

CA: ANTERIOR TRIANGLE OF THE NECK

SHIFT # 1
[Dr. Santos] | [September 3, 2019]

III. INTERNAL, EXTERNAL, AND COMMON CAROTID

ARTERIES
OUTLINE
I. External Jugular Vein VII. Thyroid gland A. CAROTID PULSE
A. Catherization A. Goiter ● Felt in the bifurcation of the carotid artery (upper border of the
II. Sternocleidomastoid and B. Cricothyroidotomy thyroid cartilage)
Platysma VIII. Parathyroid gland ● Externally, it is present at the lateral side of the laryngeal
III. Internal, External, and IX. Trachea prominence just before the SCM
Common Carotid Arteries X. Citations B. CAROTID SINUS
A. Carotid Pulse XI. References
● Pressure receptor
B. Carotid Sinus
● Glossopharyngeal nerve detects the increased pressure →
C. Internal Carotid Artery
impulse to the vagus nerve → decreased BP → decreased
IV. Internal Jugular Vein
blood supply to the brain → dizziness or syncope
A. Laceration
→ May cause ISCHEMIA in patients with carotid sinus
V. Central Venous Access
sensitivity
A. Dialysis
B. Best Access Carotid Massage
VI. Subclavian vein and artery ● For patients with supraventricular tachycardia (SVT)
A. Subclavian Vein → SVT is the contraction of the ventricles independent of the
Catheterization normal rate of the heart
B. Subclavian Artery → No blood in the heart chambers of the patient
C. Cervical Lymph Nodes ● C/I in patients with: Atherosclerosis, high lipid levels, smokers,
diabetics, with history of heart problem
I. EXTERNAL JUGULAR VEIN → Why?
▪ Plaques are deposited in blood vessels
▪ Bifurcations are common sites of plaque buildup due to
A. EXTERNAL JUGULAR VEIN POSITIONING turbulent flow
▪ Carotid massage may cause dislodgement of the plaque,
• Not visible in upright sitting position. causing THROMBOEMBOLISM leading to STROKE/CVA
• Visible in 30° in supine position, blood will be pooling down
C. INTERNAL CAROTID ARTERY
to subclavian vein 1/3 height of neck
• Prominent when hitting a high note due to increased ● Has a straighter course compared to ECA
intrathoracic pressure ● A thrombus will cause paralysis at the same side of the face,
and paralysis the extremities of the opposite side
→ Blindness at the same side of thrombus can also occur
B. CATHETERIZATION Diagnosis of Atherosclerosis
● Line for newborns on infants and newborns are preferred to be ● Carotid Ultrasound/Duplex
used here. → Carotid with plaque will CONSTRICT before dilation
▪ Newborns/infants have a tendency to kick, EJV is ● X-ray
more secure than lines on the lower extremities IV INTERNAL JUGULAR VEIN
▪ Right side is preferred due to a straighter course to
the heart A. LACERATION
● Once cut, will appear as expanding hematoma
● Slow increase in size due to blood pool (expanding hematoma)
II. STERNOCLEIDOMASTOID AND PLATYSMA can be because of two reasons:
A.STERNOCLEIDOMASTOID → IJV is a vein (low pressure)
▪ No smooth muscles
• Suicide attempts by throat cutting often fail. SCM → IJV is held by the carotid sheath
contracts and carotid sheath is protected. ▪ IJV can neither contract nor resist
• Structures in carotid sheath → Clamping can be done, but only very carefully
▪ Common Carotid Artery → Clamping may lacerate:
▪ Internal Carotid Artery ▪ Vagus nerve
▪ Vagus Nerve − Nerves CANNOT regenerate
▪ Internal Jugular Vein ▪ Hypoglossal nerve
− Paralysis of one side of tongue (hypoglossal nerve
B.PLATYSMA palsy)
▪ Muscle of facial expression →thorax to lower lip and skin
over mandible, superficial fascia
▪ Thyroidectomy – when cutting through platysma. Make
sure to cut layer by layer, otherwise, when stitched
together, platysma will contract with other layers
▪ Must be carefully closed layer by layer.

Figure 1. Hypoglossal nerve palsy

Trans # 9 Group A: See, Sharma, Sia, Sicat, Silang 1 of 3

 V. CENTRAL VENOUS ACCESS
A. DIALYSIS
● Dialysis for total parenteral nutrition
● Done when the GI tract is unable to digest and absorb
● Glucose is given straight to the blood vessel
● Why central venous?
Figure 5. Diaphragmatic paralysis
→ It is the most accessible
→ Fluid given is toxic to blood vessels, that’s why bigger blood
vessels to use are advised VI. SUBCLAVIAN VEIN AND ARTERY
→ Most accessible in the central venous are: A. SUBCLAVIAN VEIN CATHETERIZATION
▪ Jugular vein
▪ Subclavian vein Approaches to catheterization
▪ Femoral vein ● Supraclavicular approach (PREFERRED)
→ SV lies immediately posterior to the medial 3rd of the clavicle
▪ Insert needle in the junction between IJV before it
becomes the brachiocephalic vein
▪ More direct course catheter insertion into the
brachiocephalic vein and superior vena cava
▪ Needle oriented downward and away from the pleura =
avoids pneumothorax
▪ Site of penetration of the vein wall is larger
− Structures the needle pierce:
Figure 2. Total parenteral nutrition
o Skin
o Superficial fascia (platysma)
B. BEST ACCESS o Investing layer of deep cervical fascia
● Best access is through the Internal Jugular Vein (right side) o Wall of the subclavian vein
● The right IJV has a straighter course
● Catheter for dialysis is inserted between the two heads of ● Infraclavicular approach
sternocleidomastoid process → SV lies close to the undersurface of the medial 3rd of the
● After catheter insertion, a chest x-ray is necessary clavicle which is a relatively safe site for catheterization
● A chest x-ray may show punctures in: ▪ Vein slightly more medially placed on the left side
→ Lungs ▪ Needle oriented upward and posteriorly towards the
▪ Because apex of lungs reaches the posterior triangle of middle of the suprasternal notch
neck − Structures the needle pierce:
▪ A puncture might result in difficulty in breathing (dyspnea) o Skin
▪ Pneumothorax o Superficial fascia
− Collapsed lung o Pectoralis major muscle (clavicular head)
− Due to leaking of air into space between lung and chest o Clavipectoral fascia
wall o Subclavius muscle
o Wall of the subclavian vein

Table 1. Complications associated in subclavian catheterization

Supraclavicular approach
● Diaphragm paralysis
● Hemothorax
● Pneumothorax
● Brachial plexus injury
Figure 3. Pneumothorax (if injury is too deep)
Infraclavicular approach
● Diaphragm paralysis
● Pneumothorax
● Hemothorax
● Internal thoracic artery injury
● Subclavian artery puncture

→ Blood vessels
▪ Hemothorax Subclavian vein thrombosis
− Collection of blood into space between lung and chest • Common cause: close relationship of the vein to the 1st rib
wall and the clavicle and the possibility of repeated minor trauma
from these structures due to contact sports (karate, rugby,
basketball, etc.)
→ Secondary to indwelling venous catheter and excessive use
of the arm at the shoulder joint
• How to remove thrombus?
opening up a blood vessel near the subclavian/axillary vein
→ inserting a catheter → pulling it outwards
Figure 4. Hemothorax
B. SUBCLAVIAN ARTERY
→ Phrenic nerve ● Massive bleeding of the upper extremity
▪ Diaphragmatic paralysis press on the clavicle → artery is pressed against the 1st rib
− Diaphragm will not contract (will not go down) → stop the bleeding
C. CERVICAL LYMPH NODES
● Acute infection
→ Node is swollen tender and painful
● Chronic infection
→ Enlarged lymph node or cancer
● Examined from behind the patient → flex neck to reduce tension

PH 1XX CA: Anterior Triangle of the Neck 2 of 3

 Hypoglossal nerve palsy [digital image]. Retrieved from
VII . THYROID GLAND https://en.wikipedia.org/wiki/Hypoglossal_nerve
Normal location of thyroid gland:
Lateral lobe: middle of thyroid cartilage Pneumothorax [digital image]. Retrieved from
Inferiorly: 5-6 Inferior border https://www.msdmanuals.com/en-au/professional/pulmonary-
Found only in the muscular triangle disorders/mediastinal-and-pleural-disorders/pneumothorax
Attached to the trachea and esophagus
Total parenteral nutrition [digital image]. Retrieved from
A. GOITER – any enlargement in the thyroid gland https://www.saintlukeskc.org/health-library/iv-care-total-parenteral-
nutrition-tpn-therapy
● Visible mass in the neck
→ HYPERTHYROID – High in thyroid hormone XI. REFERENCES
→ HYPOTHYROID – No thyroid hormone working Doctor Santos. (2019). General lecture in clinical anatomy for anterior triangle of
→ EUTHYROID – Normal functioning thyroid neck.
→ Compressive symptoms:
▪ Dyspnea – difficulty in breathing
▪ Dysphagia – difficulty in swallowing
→ Tx: Thyroidectomy
1. Ligate the blood vessel.
a. Must take note of the blood supply
i. Superior thyroid
1. Origin: external carotid
ii. Inferior thyroid
1. Origin: thyrocervical
b. Venous drainage
i. Internal jugular vein (2) - superior and middle
thyroid
. ii. Brachiocephalic- inferior thyroid
2. Identify the nerve to the superior thyroid
a. EXTERNAL OF THE SUPERIOR LARYNEGEAL NERVE
- close the superior thyroid vein and artery
- innervates the cricoid muscle (tenses the vocal
chord)
INJURY TO THIS NERVE: low pitch of voice
c. RECURRENT LARYNGEAL NERVE
-Close to the inferior thyroid artery
-innervates the intrinsic muscles
- unilateral affectation
- hoarseness of voice
- unable to phonate.
-bilateral affectation
- stridor (airway obstruction).
-Tx: Cricothyroidotomy or tracheostomy
B. CRICOTHYROIDOTOMY- fastest way to allow airway access;
useful in emergency situations.
-it is where a tube is place between the cricoid and thyroid
cartilage

VIII. PARATHYROID GLAND

-it is located inside the capsule of the thyroid gland
posteriorly
-upper pairs = middle of the thyroid gland
-lower pairs = on the base of the lower part of the lobe
-Key roles: regulation of the calcium levels in the blood and
within the bones, this is key in muscle contraction.
HYPOPARATHYROIDISM – results to hypocalcemia.
SIGNS
1.Circum oral numbness (early sign)
2. Tingling sensation of the finger ( early sign)
3. Chvostek’s sign (resulting muscle spasm when the
parotid gland is tapped over the facial nerve).
3. Trousseau’s sign – inflate sphygmomanometer
resulting to thubadduction , MCP flexion, IP extension and wrist flexion.
TX : IV Calcium
Why? Because it is an emergency situation there
will be fast absorption.
▪

IX. TRACHEA
TRACHEOSTOMY
-Usual site: tracheal rings 2-3 or 3-4
- need to retract isthmus.

X. CITATION
Diaphragmatic paralysis [digital image]. Retrieved from
https://radiopaedia.org/cases/diaphragmatic-paralysis-1
Hemothorax [digital image]. Retrieved from https://coreem.net/core/traumatic-
hemothorax/

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