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06 MUSCLES AND TRIANGLES OF THE NECK

Dr. Ngalob| August 24, 2020 B. Posterior Triangle

OUTLINE
I. TRIANGLES OF THE NECK
a. Anterior Triangle
b. Posterior Tiangle
II. SUPERFICIAL FEATURES
III. TRIBUTARIES OF THE INTERNAL JUGULAR VEIN
IV. MUSCLES OF THE NECK
a. STRAP Muscles

Figure 1. The Anterior Triangle

I. TRIANGLES OF THE NECK
A. Anterior Triangle
Bounded by :

 Midline of the neck in front from the symphysis of the

mandible above to the sternal notch below
 Anterior of Sternocleidomastoid (SCM) behind
 Lower border of the mandible to mastoid process
Importance: most tumors in the neck area occur in the
anterior triangle

 Subdivided into 3 subsidiary triangles by the BELLIES OF

THE DIGASTRIC and OMOHYOID MUSCLES
o Digastric Triangle - bounded by the:
- anterior belly of the digastric in front
- the posterior belly of the same muscle behind
- border of the mandible above
Vessels of the Neck
- submandibular gland found within
o Carotid Triangle - bounded by the;
- superior belly of the omohyoid below
- the SCM behind
- posterior belly of the digastric above
- -carotid sheath found inside (containing CCA,
IJV, vagus nerve)
o Muscular Triangle - bounded by the:
- superior belly of the omohyoid above
- the SCM below
- the midline of the neck in front
- thyroid glands found within

Submental Triangle
region of the neck bounded by the body of the hyoid bone
below and the anterior bellies of the digastric on each side.
not part of the anterior triangle because it crosses both
anterior and posterior triangle Figure 2: Vessels of the Neck

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 Some of the fibers of this muscles may reach the face and mingle
with the risorius and the depressor muscles. It is a muscle of
o Carotid arteries expression, thus is innervated by the cervical branch of the
Each arises differently: RCcA (right common C.A.) from facial nerve. Lacking in the middle of the neck, hence, is the
innominate (brachiocephalic) artery, LCcA (left common perfect site to access the thyroid/trachea during surgery
C.A.) from arch of aorta
Branches of the Facial Nerve - Two Zanzibar By Motor Car
At the level of the thyroid cartilage, divides into 2 terminal (Temporalis, Zygomatic, Buccal, Mandibular and Cervical)
branches: the internal & external carotid arteries
o Internal carotid artery How do we test the function of each branch?
- Vertebral level: C3 Temporalis - raise the eyebrows
- Larger of the 2 terminal branches Zygomatic - squint your eyes
- Supplies the brain and eyes Buccal - pop the face, puff the cheeks
- No branches in the Neck Mandibular - pop the face, show teeth, cervical grimacing
o External carotid artery Cervical - tense the neck
- Vertebral level: C3 Significance: These tests will tell if the nerves are undamaged,
- Smaller of the 2 terminal branches thus dictating the success of a surgery.
- Has 2 terminal branches:
superficial temporal 3. LYMPH NODES
maxillary arteries
- Has 8 branches
5 BELOW the digastric muscle
Superior thyroid
Lingual
Facial/external maxillary
Ascending pharyngeal
Occipital
3 ABOVE the digastric muscle
Posterior auricular
Superficial temporal
Internal maxillary
o External jugular vein
- Begins at lower parotid and joins the subclavian
vein at its termination
o Internal jugular vein
- Begins at the jugular foramen, about ½ inch
below the base of the skull and ends at the
clavicle where it meets the subclavian vein and Figure 2: The Six Levels of Lymph Node
forms the innominate vein  6 levels:
Ia - Submental
II. SUPERFICIAL FEATURES Ib - Submandibular
 SKIN is loosely attached, especially anteriorly. Favors plastic II - Upper jugular
surgery because it is rich in blood supply. Skin at the posterior III - Middle jugular
area (nape) is very thick, adherent, and contains numerous IV - Lower jugular
sebaceous glands which explains the frequency of furuncles and Va - Upper posterior
carbuncles in this area. Vb - Lower posterior
VI - Anterior central
Furuncles and carbuncles happen when hair follicle is obstructed *VII - Chest/ Mediastinal
and the sebum and other products of metabolism cannot perspire
out of the skin. Importance: Tumors of the cervical area are often spread by the
lymph nodes. For the thyroid cancers which begin at level VI. It can go
What is the difference between furuncles and carbuncles? immediately to II, III and IV. Hence, the thyroid (level VI), including
 FURUNCLE - single infected follicle, with a single lymph nodes II, III and IV should be removed.
draining sinus
 CARBUNCLE - confluence of furuncles, with multiple Cancers:
draining sinuses. Level 1a: floor of mouth, anterior mandible, tongue, lower lip
Level 2a: oral cavity, nose & midface
Level 2, 3 & 4: pharynx, larynx, parotid glands & esophagus
 PLATYSMA MUSCLE Level 5: thyroid & parathyroids, larynx & esophagus
Rhomboidal muscle over the superficial fascia. Lacking in the Significance: Certain areas of the head will only manifest at
midline, hence, it is the perfect site to access the thyroid/trachea certain areas of the lymph node eyes
during surgery. 1st muscle encountered in any neck surgery

Origin: Fascia of Pectoralis Major and Deltoid

Insertion: Lower border of the Mandible

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 Thyrohyoid
- short muscle as continuation of the sternothyroid
III. TRIBUTARIES OF INTERNAL JUGULAR VEIN
- elevates the larynx

Digastric Muscle - presence of 2 bellies connected by a common

tendon

1. Anterior Belly - placed on surface of the mylohyoid muscle

 innervated by the trigeminal nerve
2. Posterior Belly - arises from the mastoid part of the
temporal bone covered by the mastoid process and the SCM.
 innervated by the facial nerve

CHECKPOINT!
1. Three subsidiary triangles in the anterior triangle
2. First muscle to be encountered in any neck sugery
3. Testing the function of the temporal branch of the facial
nerve is done through _____
Figure 3: Intrajugular Vein 4. Obstruction of hair follicles lead to ____
5. Structure that crosses both anterior and posterior triangle
o Inferior petrosal veins
o Pharyngeal veins Submental Triangle 5.
o Common facial vein - largest and most important
o Lingual vein
Furuncles and carbuncles 4.

o Superior thyroid vein

Raising the eyebrows 3.
o Middle thyroid vein
Platysma 2.
Digastric, Carotid, and Muscular triangles 1.
Cranial nerves passing into the neck area:

o Glossopharyngeal (9th) - goes to the anterior part of the jaw

o Vagus (10th)
o Spinal accessory (11th) - goes to the nape area
o Hypoglossal (12th) - goes to the tongue area
Importance: Tumors at the junction of the head and neck will
most likely affect these nerves

IV. MUSCLES OF THE NECK

A. STRAP muscles (ribbons)
 Depressors of the larynx - composed of TOSS
Composed of: T-O-S-S
T - thyrohyoid
O - omohyoid
S - sternohyoid
S - sternothyroid
 ALL except the Sternothyroid are attached to the hyoid
 ALL are innervated by the hypoglossal nerve
Sternohyoid
- depresses the hyoid
- origin: Manubrium sterni
- Insertion: Medial lower body of hyoid

Omohyoid
- depresses the hyoid and draws it backward and laterally
- 2 parts:
Inferior belly and
Inferior belly connected by an Intermediate
tendon
Sternothyroid
- most important surgical landmark in thyroid surgery
- if the thyroid is enlarged, this muscle becomes thin; if this
happens, the cleavage plane is difficult to find.
- depresses the larynx

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CASES: Answers:
1. A 21-year-old male trauma patient was brought to the ER by the
EMS. A knife is impaled on his neck. Point of entry is on the left
lateral neck 3cm immediately below the lobe. The tip of the
knife is seen on the right lateral neck about 1cm directly above
the clavicle. Patient is starting to crash and was transferred to the
operating room.

The following structures may be injured EXCEPT:

a. Left common carotid artery
b. Right internal jugular vein
c. Trachea
d. Level III lymph nodes, left
e. Anterior belly of the digastric

2. While kissing your beloved girlfriend (for good luck in her first
anatomy quiz) she accidentally swallowed her dentures. You noted
immediate respiratory distress and after a few minutes is already
becoming cyanotic. You tried removing the stuck dentures but your
size 9 hand just… won’t do the job.

What life-saving surgical procedure may be done to relieve the

upper airway obstruction?
a. Cricothyroidectomy
b. Cricothyroidostomy
c. Cricothyroidotomy 1. E.
d. Take a picture of the lodged denture and then PM to Dr.
Cinio via Messenger, and wait for his response 2. C.
“-ectomy”: removal
3. In performing the Sistrunk Operation, the following “-ostomy”: exteriorizing a part
nearby/adjacent structures should be identified and isolated to avoid “-otomy”: creation of a hole
post-operative complications EXCEPT: 3. C.
a. Glossopharyngeal nerve Sistrunk Operation: removal of a thyroglossal duct
b. Recurrent laryngeal nerve cyst and middle portion of the hyoid
c. Sternothyroid muscle bone
d. Omohyoid muscle
e. Thyrohyoid muscle

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