APPLIED SURGICAL ANATOMY OF TRIANGLES OF HEAD &NECK

PRESENTED BY ABHISHEK MOTIMATH

TRIANGLES OF NECK
ANTERIOR TRIANGLE: 1.SUBMENTAL TRIANGLE 2.SUBMANDIBULAR/DIGASTRIC TRIANGLE 3.MUSCULAR TRIANGLE 4.CAROTID TRIANGLE

POSTERIOR TRIANGLES
• 1. OCCIPITAL TRIANGLE • 2.SUBCLAVIAN TRIANGLE

BACK OF NECK TRIANGLE 1.Suboccipital triangle

Anterior Triangle .

Posterior Triangle of the Neck .

nerves.The Neck • Connects the head to the trunk • Conduit for blood vessels. and hollow organs • All of these complicated structures are packed in a very narrow area that allows for a great deal of mobility for the head as it moves relative to the ground .

FASCIA OF NECK Superficial fascia: .Completely surrounds neck -thin and hard to demonstrate .Contains Platysma & Superficial veins .Connective tissue below dermis .

Deep Cervical Fascia • Form the boundaries of compartments • Fascial spaces can communicate infection or fluid to other regions of the body • Used as a guide to surgical dissection • Allow the neck structures to glide past one another • Supports the thyroid. lymph nodes .

Deep Cervical Fascia .

Deep Cervical Fascia .

b/n prevertebral and buccopharyngeal • Pretracheal .below tongue – deep portion above mylohyoid – superficial portion below mylohyoid Deep Cervical Fascial Spaces .• Retropharyngeal .lat to pharynx and communicate with RP and SM spaces • Submandibular .b/n infrahyoids and trachea • Lateral pharyngeal .

Anterior Triangle of the Neck .

and anterior belly of the digastric • Carotid triangle--formed by the superior belly of the omohyoid. and midline • Submandibular triangle--formed by the mandible. and posterior belly of the Digastric • Muscular triangle--formed by the . hyoid.ANTERIOR TRIANGLE • Sub mental triangle--formed by the anterior belly of the digastric. posterior belly of the digastric. SCM.

Muscular Triangle .

• Superficial –sternohyoid and omohyoid • Deep-sternothyroid and thyrohyoid .Contents of MUSCULAR TRIANGLE • No significant structure is present • Beneath its floor lie thyroid glands.larynx.trachea.esophagus • Infrahyoid muscle are present in this triangle • Infrahyoid muscles are arranged in two layers.

Submental Triangle .

adjoining gums.floor of the mouth and tip of tongue • Commencement of ant. Jugular vein .3 or 4 in no. situated in the superficial fascia below the chin and drains the lymph from the central part of lower lip.Contents of submental triangle • Submental lymph nodes.

DIGASTRIC TRIANGLE .

overlapping the posterior belly • ECA • Carotid sheath .Superficial part of submandibular gland . Contents of digastric triangle • A part of hypoglossal nerve • Lower part of parotid gland . Facial vein and submandibular lymph nodes lie superficial to the glands Facial artery.

CAROTID TRIANGLE .

CONTENTS OF CAROTID TRIANGLE • Arteries. • In the carotid triangle the INT CAROTID is posterolateral while EXT CAROTID is anteromedial • CCA and INT CAROTID artery do not give any branches in this triangle . CCA and its two terminal branches internal and external .

CONTENTS OF CAROTID TRIANGLE

NERVES PRESENT IN THE CAROTID TRIANGLE
• Portion of spinal part of accessory nerve • Loop of hypoglossal A) Descendens hypoglossi ;supplies the sup. Belly of omohyoid B) Nerve to the thyrohyoid • Vagus nerve; passes downward within carotid sheath between IJV laterally and carotid system of arteries medially In fact vagus is not a content of this triangle as it overlapped by SCM

• Internal jugular vein; extends from the base of skull to the root of neck and collects blood from the brain ,superficial part of the face and neck • Also present are the tributaries of IJV such as sup. Thyroid, lingual ,common facial, pharyngeal,and sometimes occipital veins

VEINS PRESENT IN THE CAROTID TRIANGLE

• • • • • Pharyngeal Superior laryngeal Branch to the carotid sinus and body Sup. Cervical cardiac Right recurrent laryngeal nerve BRANCHES OF VAGUS NERVE IN THE NECK . And inf.

The inferior parts contain several important structures 1) CCA medially 2) IJV laterally 3) Vagus nerve posteriorly 4) Ansa cervicalis 5) Deep Cervical lymph nodes lie along the carotid sheath and IJV 6) Cervical part of sympathetic trunk runs .CAROTID SHEATH It is a tubular thickly matted fascial condensation extend from the base of skull to the root of neck.

BRANCHES OF EXTERNAL CAROTID ARTERY IN CAROTID TRIANGLE • Superior thyroid artery • Lingual artery • Facial artery • occipital artery • Ascending pharyngeal artery .

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APPLIED ANATOMY OF CAROTID TRIANGLE Pulse of carotid triangle by placing the digits in the triangle and compressing the artery slightly against transverse process of the cervical vertebra Carotids sinus .vagus. sympathetic nerves and it act as chemoreceptor Potato tumor of neck is produced by the enlargement of the carotid body.receives rich nerve supply from the glossopharyngeal . Tumor moves transversely .acts as baroreceptor Carotid body .shows transmitted pulsation and is often associated with slow . dilatation of the proximal part of ICA .

• Vagus nerve and recurrent laryngeal nerves are in risk to damage during surgery in this triangle. Damage to this nerve may produce alteration in the voice • When surgery of tongue is to be done and one need to ligate lingual artery then 1st part of the artery present in this triangle is ligated • Blind clamping of IJV –not done coz vagus and hypoglossal nerve are in vicinity • Carotid sheath-can be marked out by a line joining the sternoclavicular joint to a point midway between the tip of the mastoid process and the angle of mandible .

• Carotid triangle provides an important surgical approach[1]carotid arterial system [2]internal jugular vein [3]vagus and hypoglossal nerve [4]cervical sympathetic trunk • Carotid sinus hypersensitivity-pressure on one or both carotid sinuses results in excessive slowing of heart rate. a fall in blood pressure and cerebral ischemia • Arteriosclerosis of internal carotid artery-extensive arteriosclerosis of ICA in the neck can result in visual impairment and blindness in the eye on the side of lesion or even motor paralysis and sensory loss on the opposite side of body • Air embolism –serious complication of a lacerated wall of the IJV coz the wall of this vein contains little smooth muscle .

the danger of tearing of IJV is not blood loss but air embolism .• During neck dissection Lower end of internal jugular vein is approached first by dividing the SCM because it is the main vein draining the primary tumor. the carotid sheath is opened to expose the IJV and it is important to identify the length of at least 2cm to facilitate ligation making sure that vagus nerve is not included.

lingual and facial.the position can be located by palpation of transverse portion of atlas over which it lies .this can be identified by dividing SCM .Upper end of internal jugular vein • Upper end of IJV is important because we have to ligate it during neck dissection . . • Here hypoglossal nerve is to be identified and preserved and can be done as it runs across the ECA .

they run behind prevertebral fascia and is safe as long as this fascia is not breached during surgery .• When ever there is a need to cut omohyoid muscle then it is to be cut through the tendon and at this point transverse cervical artery n vein is encountered and is to be ligated • Phrenic nerve and brachial plexus is to be protected.

Posterior Triangle of the Neck .

BOUNDARIES: • Front. anterior border of trapeezius muscle • Below. • 1)semispinalis capitis muscle • 2)splenius capitis • 3)levator scapulae • 4)scalenus medius and OCCIPITAL TRIANGLE . post. Belly of omohyoid • Floor. inf. Border of SCM • Behind. formed from above downward by .

c3) 4th .c4) UPPER TRUNK OF BRACHIAL PLEXUS.Contents of occipital Fourtriangle branches cutaneous of the cervical plexus • • • • • 1st.lesser occipital nerve(c2) 2nd. by c5.great auricular nerve(c2.Supraclavicular nerve(c3.transverse cervical nerve(c2.c6 roots peeps in occipital triangle between scalenus medius and inferior belly of omohyoid .c3) 3rd.

supply rhomboid muscle • occipital artery • transverse cervical artery and vein . • 3rd and 4th cervical nerve • dorsal scapular nerve .CONTENTS OF OCCIPITAL TRIANGLE • spinal part of accessory nerve.

Preservation of Spinal accessory nerve • Whenever we do surgery in the posterior triangle then we have to keep in mind that this nerve runs in the roof and not floor and hence can be damaged during elevation of flap itself. How to identify this nerve.nerve exit point which is called ERB’S POINT which is 1cm above point where great auricular nerve winds around SCM on its way to . • 1.

SUPRACLAVICULAR TRIANGLE .

Contents of supraclavicular triangle [1]nerves(a)three trunks of brachial plexus (b)nerve to serratus anterior (c)Nerve to subclavius (d)Suprascapular nerve [2]vessels(a)Third part of subclavian artery and subclavian vien (b)Suprascapular artery and vein (c)Commencement of transverse cervical artery (d)Lower part of external jugular vein [3]lymph nodes(a)Few members of supraclavicular chains .

ACCESSORY N. TRANSVERSE CERVICAL NERVE EXTERNAL JUGULAR VEIN SUPRA CLAVICULA R NERVES . LESSER OCCIPITAL N.CONTENTS OF POSTERIOR TRIANGLE OCCIPITAL ARTERY GREAT AURICULAR N.

the resulting paralysis involves the following muscle supplied by nerve c5.infraspinatu Applied part of posterior triangle . Here c5 and c6 roots unite to form the upper trunk .Area of the upper trunk of brachial plexus which is most exposed to shearing force.which gives off two branches .deltoid.supraspinatus.• ERB’S POINT.nerve to subclavius and suprascapular nerve. • ERB’S-DUCHENNE PARALYSIS: commonest type of injury occurring at birth and produced by excessive stretching of upper trunk at the ERB’S point from the pressure of forceps used during delivery .c6.

flexor of the digits producing ‘claw hand’ .• KLUMPKE’S PARALYSIS: takes place due to injury of c8 and TI nerves .by the unopposed action .the resulting paralysis of serratus anterior is manifested by backward projection of scapula when the arm is held forward .this is called ‘scalenus anterior syndrome’ • INJURY TO THE LONG THORACIC NERVE: sometimes observed in porter who have to carry heavy load on shoulder .before or after formation of lower trunk.may be caused by pressure of a cervical rib .sometimes sagging of the shoulder girdle due to weakness and fatigue of muscle allows compression of the lower trunk against scalenus anterior muscle . the paralysis affect the intrinsic muscle of the hand .

inserting a syringe needle into the proximal part of the sheath and then injecting the local anaesthetic .• Palpation and compression of the subclavian artery in patient with upper limb hemorrhage-can be stopped by exerting strong pressure downward and backward on the third part of subclavian artery against the upper surface of first rib • Pleura and lung injuries in the root of the neck-cervical dome of the pleura and the apex of the lung extend upto the root of the neck on each side and lie behind subclavian artery so penetrating wound above the medial end of the clavicle may involve the apex of the lung • Brachial plexus nerve block-can easily be obtained by closing the distal part of axillary sheath in axilla with finger pressure .

and in malignant growth of the breast.or chest • Left supraclavicular node or Virchow or scalene nodes involve in malignant growth of distant organ so they are therefore known as signal nodes • Torticollis or wry neck in which head is bent to one side and chin points to the other side results from spasm or contraction of SCM . Hodgkin’s disease.arm.trapezius supplied by spinal accessory nerve .• Most common swelling in the posterior triangle due to enlargement of the supraclavicular lymph nodes which are commonly enlarged in tuberculosis.

• Second part of subclavian artery may get compressed by the scalene anterior muscle resulting in decreased blood supply to the upper limb • Cervical rib may compress the subclavian artery resulting in diminished radial pulse or obliterated on turning the patient’s head upward and to the affected side after a deep breath [Adson’s test] • Dysphagia caused by compression of eosophagus by an abnormal subclavian artery is called Dysphagia lusoria • Blalock’s operation for fallot’s tetra logy .the right subclavian artery is anastomosed end to side to .

SUB OCCIPITAL TRIANGLE .

Here the artery gives muscular branches to supply the sub occipital muscles and meningeal branches to the posterior cranial fossa • FIRST CERVICAL NERVE(SUBOCCIPITAL NERVE).Contents of sub occipital triangle • THIRD PART OF VERTEBRAL ARTERY.supply the muscle of surrounding area • SUB OCCIPITAL VENOUS PLEXUS. in and around the sub occipital triangle .

Ascends medial to the greater occipital nerve to supply the back of neck up to the external occipital protuberance • Occipital artery.it pierces the trapezius muscle and supply the posterior part of scalp up to the vertex. • Third occipital nerve.• Greater occipital nerve. thickest cutaneous nerve of the body curls around obliquus capitis inferior . Descending branch of this artery here maintain collateral Structures related to this triangle .

the needle pierces the posterior atlanto occipital membrane at a depth of about 4-5 cm (as indicated by sudden loss of resistance ) and enters cisterna puncture .Applied anatomy • Cisternal puncture is often employed through the sub occipital region to collect CSF from the cisterna magna.

various midline swelling in anterior triangle .(from above downward) • Ludwig's angina • Enlarged sub mental lymph nodes • Sublingual dermoid • Thyroglossal cyst • Sub hyoid bursitis • Retrosternal goiter .

Lateral swellings in the neck • In the submandibular triangle- 1.Enlargement of submandibular gland 3.Extension of growth from the jaw .Deep or plunging ranula 4.Enlarged lymph node 2.

IN THE CAROTID TRIANGLE • Carotid body tumor • Branchial cyst • Aneurysm of carotid artery • Thyroid swelling • Laryngocele • Lymph node swelling .

IN THE POSTERIOR TRIANGLE • Enlarged supraclavicular nodes • Cystic hygroma • Pharyngeal pouch • Subclavian aneurysm • Cervical rib • Lipoma .

Congenital neck masses Lymphangiomas-occur in infants and children .Important neck masses 1. Treatment is .tending to be more common in submandibular and supraclavicular region. Midline dermoid-present as solid or cystic masses in the midline of the neck between the suprasternal notch and sub mental region.

2/3 lies anterior to the upper third SCM.1/3 in middle and .mostly painless and moves on swallowing or protruding the tongue with mean age 5 years.• Thyroglossal duct cysts-most common midline neck cyst . Treatment is by excision • Thyroglossal duct carcinoma-may be suspected if the cyst is hard and irregular or recently undergoes changes • Branchial cyst-2/3 of this is present on left and 1/3 on right side is affected.

• Branchial fistula –external opening is at the external border of the SCM .TRACT runs below the stylohyoid muscle and posterior belly of Digastric above the hypoglossal nerve • Haemangiomas-most common benign tumors of infancy and is present most often within the masseter and trapezius muscle .at the junction of the middle and lower thirds and internal opening on the anterior aspect of tonsillar fossa.

plunging ranula result from the extravasattion of mucus below the mylohyoid muscle and present as painless .manual compression may result in the escape of gases and fluid into the airway (BRYCE’S SIGN) • Pharyngeal pouches are also seen Acquired neck masses .non mobile neck swelling • Laryngoceles –arise within the saccule of the laryngeal ventricle.• Ranulas-cystic mass in the floor of the mouth or tongue .

Infective neck masses • Para pharyngeal abscess –more common in adults and is complication of tonsillectomy or tonsillitis or extraction of third molar or due to the extension of infection from the petrous part of temporal bone .neck swelling is maximal at the posterior midthird of sternocliedomastoid muscle's/t is I/D the space being opened from a point medial to the mandible to the clavicle .

• AIDS-head and neck manifestation are seen • Toxoplasmosis-caused by toxoplasmosis Gondi • Actinomycosis• Infectious mononucleosis • Brucellosis• Tuberculous cervical lymphadenitislong standing lymphdenopathy due to tuberculosis .usually the deep jugular chain .although the posterior triangles nodes can also be affected .

CHAURASIA • GRAY’S ANATOMY • TEXTBOOK OF ANATOMY: A.REFERENCE • TEXTBOOK OF ANATOMY: B.D.K.DUTTA • ATLAS OF HUMAN ANATOMY : FRANK NETTER .

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