Thyroid Gland + Neck

Organs located in the neck

- Larynx
- Thyroid
- Parathyroid glands

Describe the osteology of the neck, including features of the cervical vertebrae and the hyoid bone
Skeleton of the neck is formed by:
- Cervical vertebrae (C1-C7)
- Hyoid bone -- @ C3 V
- Manubrium of sternum
- Clavicles

Hyoid bone
- @ C3 V in the angle between the mandible + thyroid cartilage.
- Doesn’t articulate with any other bone
- Functionally serves as an attachment for anterior neck muscles + a prop to keep the airway open.
- Anatomy:
o Greater horn
o Lesser horn
o Body
o Fibrocartilage

Cervical Vertebrae
- Bifid spinous process (spinous process bifurcates at its distal end).
o Except C1 (has no spinous process) + C7 (spinous process is longer than that of C2-6 and may nor bifurcate)
- Transverse foramina x2 = through which the vertebral arteries travel to brain
- Large + Triangular vertebral foramen
- C1 (atlas) and C2 (axis) = specialised to allow movement of head.

C1 Atlas

C2 Axis
- No transverse foramina

C3-C7

Fascia of the Neck

Neck fascia COMPARTMENTALISE structures within the neck.
These layers can LIMIT the spread of infection

Cervical subcutaneous tissue of neck/ superficial cervical fascia

- Lies between dermis of skin + investing layer of deep cervical fascia
- Fatty, subcutaneous tissue
- Contents:
o Cutaneous nerves
o Blood vessels
o Lymphatic vessels
o Supeficial lymph nodes
o Variable amounts of fat
o Platysma:
▪ Anterolateral to the superficial cervical fascia
▪ Is a muscle of facial expression – v important for conveying facial tension
▪ Broad thin sheet of muscle
▪ Can relieve pressure on IJV
▪ Innervation: CN 7
Q) what is special about the contents of the superficial fascia?
- It contains a muscle!! the platysma
- The only other place in the body where you see this specialisation of superficial fascia is in the testes with the dartos muscle
Deep Cervical Fascia
Has 3 layers. Role: support viscera, muscles vessels, deep lymph nodes. Provide slipperiness to allow structures in neck to move + pass over
one another (ie swallowing, turning neck)

Investing layer Pretracheal layer Prevertebral layer

Characteristics - The most superficial deep cervical - Thin layer - Forms tubular sheath for
 fascia layer
- Surrounds entire neck
- Deep to skin + subcutaneous tissue
Continuous - Is continuous posteriorly with the
with periosteum covering C7 spinous
process + nuchal ligament
- Anteriorly: blends with carotid sheath
Attachments - Superiorly: attaches to superior nuchal
line of occipital bone, mastoid process
of temporal bones, zygomaticx arches,
inferior border of mandible, hyoid +
spinous process of cervical V.
- Inferiorly: attaches to manubrium,
clavicles, acromions, spines of
scapulae
- Limited to anterior part of neck
- Has 2 parts
- Posterosuperiorly : continuous
with buccopharyngeal fascia
- Laterally + anteriorly: blends with
carotid sheaths
- Extends from hyoid 🡪 thorax
where it blends with fibrous
pericardium covering the heart
(clinical implication see below)
vertebral column + muscles
associated with it
-
- Posteriorly: blends with
carotid sheaths
- Extends laterally as the
axillary sheath = surrounds
axillary vessels + brachial
plexus
- Superiorly: cranial base
- Inferiorly: cranial base
- Centrally: fuses with anterior
longitudinal ligament @T3

What it - @ the ‘4 corners’ of the neck = the Has 2 parts Forms tubular sheath for vertebral
encloses investing layer splits into superficial + - Thin muscular part. Encloses the: column + muscles associated with it:
deep layers of deep fascia to enclose: o Infrahyoid muscles - Longus colli (anteriorly)
o R + L sternocleidomastoid - Visceral part. Encloses the: - Longus capitis (anteriorly)
o Trapezius – thus the o Thyroid gland - Scalenes (laterally)
investing layer is v large!! o Trachea - Deep cervical muscles
- @ inferior to its attachment at o Oesophagus (posteriorly)
mandible, it splits to enclose:
o Submandibular gland. Buccopharyngeal fascia is the posterior
- @posterior to the mandible it splits to aspect of the visceral Pretrachial fascia
form the:
o Fibrous capsule of the
parotid gland
- SUPRASTERNAL SPACE: Just superior
to the manubrium, the fascia remains
divided into the two layers that
enclose the sternocleidomastoid. one
layer attaches to the anterior and the
other to the posterior surface of the
manubrium. A suprasternal space lies
between these layers and encloses the
inferior ends of the anterior jugular
veins, the jugular venous arch, fat, and
a few deep lymph nodes

CAROTID SHEATH
- Tubular fascial investment
- Extends from cranial base 🡪 root of neck /thoracic mediastinum.
- Are paired structures on either side of the neck
- Its fascia is formed by contributions from all 3 deep cervical fascia layers
- V important as it contains:
o Common carotid artery + Internal carotid artery
▪ The common carotid artery bifurcates in the sheath ( 🡪 internal + external carotid artery) however the external
carotid artery is not in the anterior triangle
o Internal jugular vein (IJV)
o Vagus nerve (CN X)
^^^ Order: (lateral to medial) IVJ 🡪 Vagus nerve 🡪 Artery
o Deep cervical lymph nodes (some)
o Carotid sinus nerve
o Sympathetic nerve fibers (carotid periarterial plexuses)
 RETROPHARYNGEAL SPACE
- A potential space
- Is between the visceral part of the prevertebral layer of deep cervical fascia and the buccopharyngeal fascia (posterior aspect of the
visceral layer of Pretrachial fascia)
- Permits movement of the pharynx, esophagus, larynx, and trachea relative to the vertebral column during swallowing.
- Extends from base of skull to posterior mediastinum
- It is a potential space that consists of loose connective tissue
- is closed superiorly by the base of the cranium and on each side by the carotid sheath.

VISCERAL SPACE
- Enclosed by visceral layer of Pretracheal fascia
- Extends from hyoid bone 🡪 superior mediastinum

Clinical implications of Fascia (spread of infection in neck)

The fascial planes:
- Determine the direction in which an infection in the neck may spread
Investing layer:
- Helps prevent the spread of abcesses (collection of pus)
o superficial skin abscesses may be prevented from spreading deeper into the neck by this fascia
- If infection occurs between the: investing layer of deep cervical fascia and the muscular part of the pretracheal fascia surrounding
the infrahyoid muscles = the infection usually does not spread beyond the superior edge of the manubrium.
- If infection occurs between the investing fascia and the visceral part of the pretracheal fascia = it can spread into the thoracic cavity
anterior to the pericardium.
Pretrachial fascia
- The carotid sheath and pretracheal fascia communicate with the mediastinum of the thorax inferiorly and the cranial cavity
superiorly. These communications represent potential pathways for the spread of infection and extravasated blood.
Prevertebral fascia + RETROPHARYNGEAL SPACE
- Pus from an abscess posterior to the prevertebral layer may extend laterally in the neck and form a swelling posterior to the
sternocleidomastoid.
- The pus may perforate the prevertebral layer and enter the retropharyngeal space, producing a bulge in the pharynx
(retropharyngeal abscess). This swelling may cause difficulty in swallowing (dysphagia) and speaking (dysarthria).
- Similarly, air from a ruptured trachea, bronchus, or esophagus (pneumomediastinum) may pass superiorly in the neck.
-
CAROTID SHEATH
- Big clinical importance as a pathway for spread of infection

Infections that reach into potential spaces between the neck + fascia have a well-defined spread.
RETROPHARYNGEAL SPACE
- It is the largest and most clinically important interfascial space in the neck because it is the major pathway for the spread of infection
- Retropharyngeal abscess + ruptured trachea etc (see above)
VISCERAL SPACE

The Deep Cervical Fascia layers produces Natural cleavage planes

- These planes allow separation of tissues during surgery

Describe the attachments, innervation + function of the Sternocleidomastoid muscle and Infrahyoid muscle

Sternocleidomastoid Infrahyoid made of 4 muscles:

Omohyoid Sternohyoid Thyrohyoid Sternothyroid
Superior - Lateral surface of - Inferior - Body of hyoid - Inferior border - Oblique line
Attachments mastoid process border of bone of hyoid bone of thyroid
(hence mastoid) hyoid bone - Greater horn of cartilage
- Superior nuchal line hyoid bone
(lateral half)
Inferior - Manubrium (hence - Scapula’s - Manubrium - Thyroid - Manubrium
Attachments sterno) (anterior superior - Clavicle’s cartilages’ (posterior
surface) for its border near medium end oblique line surface)
sternal head suprascapular
- Clavicle (hence notch
cleido) for its - Has 2 bellies
clavicular head (superior +
inferior)
Function - Flex neck laterally + - Depress hyoid <<<< - Depresses - Depresses
anteriorly bone after its hyoid bone hyoid bone
- Rotate head been elevated - Elevates larynx - Depresses
contralaterally to during larynx
side of contraction swallowing
- Depress,
retaracts + <<<<
stabalises
hyoid bone
- yPulls on
carotid
sheath =
prevents IJV
collapsing and
to help
maintain
pressure
Innervation - Accessory nerve (CN - C1-C3 by a <<<< - C1 via C2-C3 by a branch of
XI) branch of hypoglossal ansa cervicalis
- Branches of cervical ansa cervicalis nerve (CN XII)
plexus (C2-3) (anterior ramus
of C1 via
hypoglossal
nerve)

Thyroid gland is deeper than hyoid bone, hence why thyrohyoid and sternothyroid are deeper than the omohyoid and sternohyoid.

Identify the divisions (regions) of the neck, the boundaries of the anterior + posterior cervical triangles, as well as their contents
So the neck is divided into
- 2 triangles (Anterior + Posterior. Each are paired structures)
o Anterior triangle then subdivides into 4 smaller triangles
- 4 regions

Anterior Triangle
Borders
- Superiorly: inferior border of mandible (jawbone)
- Laterally: anterior border of the sternocleidomastoid
- Medially: Sagittal line down midline of the neck
Roof
- Investing fascia
Floor
- Visceral fascia
Muscles
- Infrahyoid muscles (see above)
- Suprahyoid muscles:
o Stylohyoid
o Digastric
o Mylohyoid
o Geniohyoid
Nerves
- Cranial nerves 7, 9-12
Veins
- Internal jugular vein
o Lies deep to the sternocleidomastoid muscle
Arteries
- Common carotid artery bifurcates 🡪 internal + external carotid
Anterior triangle is subdivided into 4 triangles:
- Carotid triangle
o Contains: IVJ, Vagus nerve, common cartory (bifurcates here), hypoglossal nerve
- Submental triangle
- Submandibular triangle
- Muscular triangle

Posterior triangle
Borders
 - Anterior: posterior border of sternocleidomastoid
- Posterior: anterior border of trapezius
- Inferior: middle 1/3 of clavicle
Roof
- Investing layer of fascia
Floor
- Prevertebral fascia
- Splenius capitis
- Levator scapulae
- Anterior, middle + posterior scalenes
^^^ all 3 of these muscles are covered by the prevertebral fascia

Muscles – it contains many muscles which make up the borders + floor of the area
- Omohyoid = split into 2 bellies by a tendon and it’s the inferior belly that crosses the posterior triangle travelling in a supero-medial
direction 🡪 crosses underneath the sternocleidomastoid to then enter the anterior triangle of neck
- Splenius capitis
- Levator scapulae
- Anterior, middle + posterior scalenes

Veins
- External jugular vein
o Lies superficially to the sternocleidomastoid
o It pierces the investing layer of fascia and empties the subclavian vein
- Subclavian vein
- Transverse cervical vein
- Suprascapular vein

Arteries
- Subclavian artery
- Transverse cervical artery
- Suprascapular artery
Nerves
- Accessory nerve (CN XI)
o Enters investing layer of fascia
- Cervical plexus
o forms within the muscles of the floor of the posterior triangle
o A major branch of the plexus is the phrenic nerve (arises from anterior divisions of spinal nerves C3-C5) – it descends
through the prevertebral fascia to innervate the diaphragm
- Trunks of the brachial plexus cross the floor

It’s the sternocleidomastoid muscle that separates the anterior and posterior triangles!!!

CAROTID SHEATH VS CAROTID TRIANGLE

- Carotid sheath is a sheath, carotid triangle is a subdivision of the anterior triangle of the neck
- Carotid sheath contains: IJV, Vagus nerve, common carotid
- Carotid triangle contains: : IJV, Vagus nerve, common carotid and the hypoglossal nerve
- Bifurcation of common carotid at C3

Clinical relevance
- Subclavian vein often used as a point of access to the venous system via a central catheter
- The external jugular vein has a relatively superficial course down the neck, leaving it vulnerable to damage. If it is severed, in an
injury such as a knife slash, its lumen is held open – this is due to the thick layer of investing fascia (for more information see Fascial
Layers of the Neck). Air will be drawn into the vein, producing cyanosis, and can stop blood flow through the right atrium. This is a
medical emergency, managed by the application of pressure to the wound – stopping the bleeding, and the entry of air.

External and Internal Carotid

- Internal = supplies brain
- External carotid = supplies brain

Describe the compartments of the neck + their contents, and identify the fascia forming these compartments
- Sternocleidomastoid region
- Posterior cervical region
- Lateral cervical region
- Anterior cervical region
- Subocippital region
Describe the anatomy of the thyroid gland (lobes + isthmus) and the clinical relations to the thyroid gland to other structures in the neck,
particularly the recurrent laryngeal nerves

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Thyroid gland anatomy

- Lies deep to sternothyroid + sternohyoid muscles
- @ C5-T1 V
- R + L lobes. Connected by isthmus.
- The lobes of the thyroid gland are wrapped around the cricoid cartilage and superior rings of the trachea.
- The gland is located within the visceral compartment of the neck (along with the trachea, oesophagus and pharynx).
- This compartment is bound by the pretracheal fascia.

Function
- Endocrine organ
- Regulates metabolic rate of body

Clinical relations to the thyroid gland

- Anteriorly – infrahyoid muscles, namely the sternothyroid, superior belly of the omohyoid and sternohyoid
- Laterally – carotid sheath (containing the common carotid artey, internal jugular vein and vagus nerve) –THINK ABOUT IT THE
CAROTID SHEATH IS A PAIRED STRUCTURE SO OBV WILL BE LATERAL TO IT
- Medially –
o Organs – larynx, pharynx, trachea and oesophagus
o Nerves – external laryngeal and recurrent laryngeal nerves (POSTERIOR)
Vagus nerve + recurrent laryngeal nerves
Recurrent laryngeal nerve (aka inferior laryngeal nerve):
- RHS: loops around subclavian artery
- LHS: loops around aortic arch before returning up to go through the tracheoesophageal groove and then the larynx.

Identify the location + functional anatomy of the parathyroid glands, and explain the common variations in their location
Parathyroid gland location
- Usually on POSTERIOR aspect of thyroid gland
- Usually 4 of them:
o Superior parathyroid glands x2
▪ Derived from 4th pharyngeal pouch
▪ Located at the middle + posterior border of each thyroid lobe
1 cm superior to the entry of the inferior thyroid artery into the thyroid gland
▪ Can be found by the by the inferior border of the cricoid cartilage
o Inferior parathyroid glands x2
▪ Derived from 3rd pharyngeal pouch
Variations
- Most people have 4, but 2-6 can occur
- Inferior parathyroid location is inconsistent between individuals
- In a small number of people, the inferior parathyroid glands can be found as far inferiorly as the superior mediastinum

Describe the arterial supply, venous drainage and lymphatic drainage of the thyroid and parathyroid glands
Thyroid gland
- Arterial supply:
highly vascularised because it secretes hormones directly into circ. 2 main arteries:
o Superior thyroid artery (1st branch of external carotid artery)
o Inferior thyroid artery (arises from thyrocervical trunk which is a branch of the subclavian artery)
o In 10% of people there is an additional artery present – the thyroid ima artery. It arises from the brachiocephalic trunk and
supplies the anterior surface and isthmus of the thyroid gland
- Venous drainage:
o Superior, middle + inferior thyroid veins = form a venous plexus around the thyroid gland.
▪ Superior + middle 🡪 drain into IJV
▪ Inferior 🡪 drain into brachiocephalic vein
- Lymphatic drainage:
o Paratracheal nodes
o Deep cervical nodes
- Innervation
o Branches off sympathetic trunk. These nerves do not control secretory function. That is done by pituitary gland.

Parathyroid glands
- Arterial supply
o Inferior thyroid artery (because its posterior and the parathyroid glands posterior surface of thyroid gland)
o Collateral arterial supply is from superior thyroid artery + thyroid ima artery
- Venous + Lymphatic drainage = same as for thyroid gland
- Innervation
o The parathyroid glands have an extensive supply of sympathetic nerves derived from thyroid branches of the
cervical ganglia.
o these nerves are vasomotor, not secretomotor – endocrine secretion of parathyroid hormone is under hormonal control. 

Branches of the External Carotid Artery (from inferior 🡪 superior)

Can be remembered by the mnemonic: Some Anatomists Like Freaking Out Poor Medical Students
- Superior thyroid artery
- Ascending pharyngeal artery
- Lingual artery
- Facial artery
- Occipital artery
- Posterior auricular artery
- Maxillary artery
- Superficial temporal artery

Discuss some of the common developmental abnormalities of the thyroid gland, and the clinical consequences of these
Accessory Thyroid Tissue
- Accessory thyroid tissue may develop in the neck lateral to the thyroid cartilage, usually, the tissue lies on the thyrohyoid muscle.
- Ie a A pyramidal lobe (an extension of thyroid tissue from the superior aspect of the isthmus) and its connective tissue continuation
may also contain thyroid tissue. originates from remnants of the thyroglossal duct—a transitory endodermal tube extending from
the posterior tongue region of the embryo carrying the thyroid-forming tissue at its descending distal end. Although the accessory
tissue may be functional, it is usually too small to maintain normal function if the thyroid gland is removed.
Clinical application
Thyroidectomy 🡪 tetany/hypocalcaemia
- During a thyroidectomy (e.g., excision of a malignant thyroid gland), the parathyroid glands are in danger of being inadvertently
damaged or removed. These glands are safe during subtotal thyroidectomy because the most posterior part of the thyroid gland
usually is preserved.
- Variability in the position of the parathyroid glands, especially the inferior ones, puts them in danger of being removed during
surgery on the thyroid gland. If the parathyroid glands are inadvertently removed during surgery, the patient suffers from tetany, a
severe convulsive disorder, muscle cramps, paraesthesia of fingers, toes + mouth. The generalised convulsive muscle spasms result
from a fall in blood calcium levels (hypocalcaemia).
- Because of this risk, it is usually standard post-operative practice to check:
o Parathyroid gland function via the parathyroid hormone and serum calcium in all patients following thyroid surgery.
o Recurrent laryngeal nerves - control all intrinsic muscles of the larynx except for the cricothyroid muscle. These muscles act
to open, close, and adjust the tension of the vocal cords, and include the posterior cricoarytenoid muscles, the only muscle
to open the vocal cords.

- Hormone replacement therapy is required.

Apply your anatomical knowledge of the neck to correctly interpret radiographic images of the cervical region

Vagus nerve + recurrent