Head Neck Face-13 (Larynx and deep

neck structures)

Dr. Santosh Ramkrishna Malwade

All Saints University School of

Medicine
Dominica, Fall 2023
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 Viscera of the Neck

Three layers of the cervical viscera

1. Endocrine layer: the thyroid and parathyroid
glands
2. Respiratory layer: the larynx and trachea
3. Alimentary layer: the pharynx and esophagus

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 Larynx (voice box)
• A musculoligamentous and cartilaginous structure that lies at the C3-C6
vertebral level, just superior to the trachea.
• It functions both as a sphincter to close off the airway and as a “reed
instrument” to produce sound.
• Its framework consists of nine cartilages joined by ligaments and
membranes.

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 Cricothyrotomy

• Cricothyroidotomy, also known as cricothyrotomy, is an important

emergency procedure that is used to obtain an airway when other, more
routine methods (eg, endotracheal intubation) are ineffective or
contraindicated.
• It is done through cricothyroid membrane, the membrane extending from
cricoid cartilage below to thyroid cartilage above.

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 Cricothyrotomy
• There are 3 main approaches to
cricothyroidotomy:
– Needle cricothyroidotomy
– Percutaneous cricothyroidotomy using the
Seldinger technique
– Surgical cricothyroidotomy

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 Needle Cricothyroidotomy

• With the dominant hand, insert the angiographic catheter, attached to the syringe filled
with normal saline, into the cricothyroid membrane, directing it caudally at a 45o angle.
• As the needle is advanced, apply negative pressure to the syringe. A distinct pop can be
felt as the needle traverses the membrane and enters the trachea.
• In addition, air bubbles will appear in the fluid-filled syringe.
• Advance the catheter, and retract the needle.
• Place an endotracheal tube adapter. A bag valve mask (BVM) can then be attached to
deliver oxygen for ventilation.

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 Musculature of the Larynx - Extrinsic
• Extrinsic Muscles
– These muscles move the larynx up
and down during swallowing
– Note that many of these muscles are
attached to the hyoid bone, which is
attached to the thyroid cartilage by
the thyrohyoid membrane.
– It follows that movements of the
hyoid bone are accompanied by
movements of the larynx.

• Elevation: The digastric, the

stylohyoid, the mylohyoid, the
geniohyoid, the stylopharyngeus,
the salpingopharyngeus, and the
palatopharyngeus muscles

• Depression: The sternothyroid,

the sternohyoid, and the
omohyoid muscles

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 Musculature of the Larynx - Intrinsic

• Intrinsic Muscles

– Two muscles modify the laryngeal inlet:

• Narrowing the inlet: The oblique
arytenoid muscle
• Widening the inlet: The
thyroepiglottic muscle
– Five muscles move the vocal folds
(cords):
• Tensing the vocal cords: The
cricothyroid muscle
• Relaxing the vocal cords: The
thyroarytenoid (vocalis) muscle
• Adducting the vocal cords: The
lateral cricoarytenoid muscle
• Abducting the vocal cords: The
posterior cricoarytenoid muscle
• Approximates the arytenoid
cartilages: The transverse
arytenoid muscle

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Laryngeal Musculature

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Laryngeal Musculature

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 Vocal Cords
• Two pairs of ligaments extend from the posterior surface of the thyroid
cartilage to the arytenoid cartilages.
• The inferior ligaments, called vocal ligaments, are covered by a mucous
membrane. These ligaments together with their mucosa are called the vocal
folds
• Vocal folds are “true vocal cords” because they produce sound when air
passes between them.

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 Vestibular Folds

• The superior ligaments are called vestibular ligaments

• Together with the mucosa covering them, they are called the
vestibular folds
• These folds are “false vocal cords” because they have no function in
sound production, but protect the vocal folds.

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 Rima Glottidis

• When intrinsic muscles of the

larynx make the arytenoid
cartilages pivot, they can abduct
or adduct the vocal folds.
• The opening between the vocal
folds is called the rima glottidis.
• This opening widens if the vocal
folds are abducted and becomes
narrower if the vocal folds are
adducted.
• The term glottis refers to the
rima glottidis plus the vocal
folds.

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 Phonation
• When air is forced through the
rima glottidis, the vocal folds
begin to vibrate, and this
vibration produces sound.
• The nonkeratinized stratified
squamous epithelium lining the
vocal folds withstands this
abrasive contact between the two
vocal folds and their vibrational
activity during sound production.
• The length, tension, and position
of the vocal folds determine the
characteristics of the sound

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 Phonation
• The range of a voice (be it soprano or bass) is determined by the length
of the vocal folds.
• Longer vocal folds produce lower sounds than shorter vocal folds. As
we grow, our vocal folds increase in length, which is why our voices
become deeper as we mature into adults.
• Also, both the growth of the thyroid cartilage and the longer and thicker
vocal folds in mature males help explain why men typically have deeper
voices than females.

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 Laryngoscopy

• A procedure that is used to obtain a view of the vocal folds and the glottis
– Direct
– Indirect
• Mirror
• Fiberoptic bronchoscopes
• Video laryngoscopes
• Fiberoptic laryngoscopes

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Direct - Laryngoscope

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Laryngeal Mirror

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 Laryngitis

• Inflammation of the larynx that may extend to the surrounding structures.

• Viral or bacterial infection is the number one cause of laryngitis.

• Less frequently, laryngitis follows overuse of the voice, such as yelling for
several hours at a football game.

• Symptoms include hoarse voice, sore throat, and sometimes fever. In severe
cases, the inflammation and swelling can extend to the epiglottis.

• In children, whose airways are proportionately smaller, a swollen epiglottis

may lead to sudden airway obstruction and become a medical emergency.

• Treatment-Antibiotics, anti virals, corticosteroids (depending upon

etiological factors)
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 Deep Structures of the Neck

The deep structures of the neck are the prevertebral muscles, located posterior to
the cervical viscera and anterolateral to the cervical vertebral column, and
structures located on the cervical side of the superior thoracic aperture, the
root of the neck.

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 Prevertebral Muscles
The anterior and lateral vertebral or prevertebral muscles are deep to prevertebral
layer of deep cervical fascia.
The anterior vertebral muscles, consisting of the longus colli and capitis, rectus
capitis anterior, and anterior scalene muscles, lie directly posterior to the
retropharyngeal space and medial to the neurovascular plane of the cervical and
brachial plexuses and subclavian artery.

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The lateral vertebral muscles, consisting of the rectus
capitis lateralis, splenius capitis, levator scapulae, and
middle and posterior scalene muscles, lie posterior to this
neurovascular plane and (except for the highly placed rectus
capitis lateralis) form the floor of the lateral cervical region.

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 Anterior vertebral muscles
Longus colli
Longus capitis
Rectus capitis anterior
Anterior scalene
Lateral vertebral muscles
Rectus capitis lateralis
Splenius capitis
Levator scapulae
Middle scalene
Posterior scalene
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 Longus colli Anterior vertebral muscles
Superior attachment
Anterior tubercle of C1 vertebra (atlas); bodies of C1 - C3 and transverse processes of C3 -
C6 vertebrae
Inferior attachment
Bodies of C5 - T3 vertebrae; transverse processes of C3 - C5 vertebrae
Innervation
Anterior rami of C2 - C6 spinal nerves
Main action(s)
Flexes neck with rotation (torsion) to opposite side if acting unilaterally

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Longus capitis

Superior attachment
Basilar part of occipital bone
Inferior attachment
Anterior tubercles of C3 - C6 transverse
processes
Innervation
Anterior rami of C1 - C3 spinal nerves
Main action(s)
Flex head

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Rectus capitis anterior

Superior attachment
Base of skull, just anterior to occipital condyle
Inferior attachment
Anterior surface of lateral mass of atlas (C1
vertebra)
Innervation
Branches from loop between C1 and C2 spinal
nerves
Main action(s)
Flex head

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Anterior scalene
Superior attachment
Transverse processes of C4 - C6 vertebrae
Inferior attachment
1st rib
Innervation
Cervical spinal nerves C4 - C6
Main action(s)
Flex head

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 Lateral vertebral muscles

Rectus capitis lateralis

Superior attachment
Jugular process of occipital bone
Inferior attachment
Transverse process of atlas (C1 vertebra)
Innervation
Branches from loop between C1 and C2 spinal
nerves
Main action(s)
Flexes head and helps stabilize it

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Splenius capitis

Proximal attachment
Inferior half of nuchal ligament and spinous
processes of superior six thoracic vertebrae
Distal attachment
Lateral aspect of mastoid process and lateral third of
superior nuchal line
Innervation
Posterior rami of middle cervical spinal nerves
Main action(s)
Laterally flexes and rotates head and neck to same
side; acting bilaterally, extend head and neck

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Levator scapulae

Superior attachment
Posterior tubercles of transverse processes C1 - C4
vertebrae
Inferior attachment
Superior part of medial border of scapula
Innervation
Dorsal scapular nerve C5 and cervical spinal nerves C3
and C4
Main action(s)
Elevates scapula and tilts its glenoid cavity inferiorly by
rotating scapula

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Middle scalene
Superior attachment
Posterior tubercles of transverse processes of C4 - C6 vertebrae
Inferior attachment
Superior surface of 1st rib; posterior groove for subclavian artery
Innervation
Anterior rami of cervical spinal nerves
Main action(s)
Flexes neck laterally; elevates 1st rib during forced inspiration

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Posterior scalene
Superior attachment
Posterior tubercles of transverse processes of C4 - C6 vertebrae
Inferior attachment
External border of 2nd rib
Innervation
Anterior rami of cervical spinal nerves C7 and C8
Main action(s)
Flexes neck laterally; elevates 2nd rib during forced inspiration

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 Arterial Supply

• The arterial supply to the neck is

by the subclavian artery and
some of the branches of the
external carotid artery

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 Arterial Supply
• Subclavian: supplies the lower neck
(thyrocervical and costocervical
trunks), thoracic wall, shoulder,
upper back, and brain (vertebral
branches)

• External carotid: supplies the

thyroid gland, larynx, pharynx, neck,
oral cavity, face, nasal cavity,
meninges, and temporal and
infratemporal regions via its eight
primary branches

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 Arterial Supply - Subclavian

• The subclavian artery is divided

for descriptive purposes into three
parts due to anterior scalene
muscle:
– Part 1 lies medial
– Part 2 lies posterior
– Part 3 lies lateral to the
anterior scalene muscle

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Arterial Supply - Subclavian

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 Carotid Arteries

• The main vessels of the head and neck are the right and left common
carotid arteries
• They divide in the carotid triangle into:
– The external carotid artery, which supplies the structures external to the
skull as well as the face and most of the neck
– The internal carotid artery, which is distributed within the cranial cavity
and the orbit

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Arterial Supply – External Carotid

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 Venous Drainage
• The venous drainage of the neck is
highly variable, but most of the blood
ultimately drains into tributaries of the
external and internal jugular veins.

• The external jugular vein is formed by

the posterior auricular and posterior
branch of the retromandibular veins,
while the internal jugular vein begins at
the jugular foramen as a continuation
of the sigmoid dural sinus

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 Venous Drainage
• Retromandibular: receives tributaries from
the temporal and infratemporal regions
(pterygoid plexus), orbit, nasal cavity,
pharynx, and oral cavity
• Internal jugular: drains the brain (dural
venous sinuses), face, thyroid gland, and
neck
• External jugular: drains the superficial
neck, lower neck and shoulder, and upper
back (often communicates with the
retromandibular vein)

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 Neck Lymphatics
Lymph nodes and vessels of the head and neck tend to follow the venous drainage, with
most of the lymph ultimately collecting in the deep cervical lymphatic chain
(jugulodigastric and jugulo-omohyoid nodes)

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• Thank you and Good luck
with Block 3 and NBME
Exams

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