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ENT

Anatomy of the Neck and Lymphatics


Lecturer: Dr. Lago | Date: January 21, 2010
Anatomical Planes

Transcriber(s): ona

Clinical Triangles of the Neck Mid Sagittal Plane vertical plane passing the center of the body, dividing the L & R half. Medial nearer the mid sagittal plane Lateral away the mid sagittal plane Coronal Plane perpendicular to mid sagittal plane, dividing the body to front and back. Anterior - going front Posterior going back Transverse Plane perpendicular to the first 2 planes, dividing the body horizontally. Superior going coronal Inferior going caudal NECK Impt to know the structures underneath each triangles bec. these structures gives you clues as to what your dealing with if your have neck ds or if the px manifest as a neck prob.

Boundaries:

bet. mandible and above clavicle enclosed superficially by skin and underlying fascia

Superior: inferior border of the mandible, tip of mastoid process, external occipital protuberance Lateral: SCM and borders of the trapezius Medial: hyoid bone, thyroid and cricoid cartilage, and thyroid gland

Borders: Anterior Triangle Superior: Mandible Anteromedial: midline Posterior: SCM (sternal and clavicular head)

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Submental triangle Boundaries: Anterior bellies of digastric and hyoid bone Floor: Mylohoid Contents: Submental art; ant. jugular vein and submental lymph nodes Submandibular triangle Boundaries: Ant., post. digastric and the lateral margin of the mandible Floor: Mylohoid and hyoglossus Contents: Submandibular gland; parotid gland; ext. carotid artery and its branches: facial and lingual; facial vein; submandibular lymph nodes and vessels; cervical branch of CN VII; CN XII Carotid triangle (check the carotid pulse) Boundaries: Sternoclenomastoid; post. digastric and sup. omohyoid Floor: Thyrohyoid, hyoglossus and pharyngeal constrictors Contents: Internal jugular v. (and branches); common carotid artery forming ext. and internal carotid arteries; sup. thyroid, lingual and facial aa; CN X; ansa cervicalis; deep cervical lymph nodes Muscular triangle Boundaries: Sup. omohyoid; sternocleidomastoid and ant. margin of neck Floor: Sternohyoid and sternothyroid muscles Contents: Larynx, trachea; thyroid gland; esophagus; paratracheal lymph nodes; Branches: Sup. and inf. thyroid aa (and their accompanying vv.); ant. jugular vein.

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Fascia of the Neck Superficial Cervical fascia encloses the platysma, cutaneous n., EJV, AJV, and superficial cervical LNs Deep Cervical fascia envelopes deep structures

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Creates pockets of spaces where infection and abcesses can sit in; but also limit the spread of infection Infection will manifest as bulges in the neck

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3 Layers

1.) 2.) 3.)

Superficial Investing Layer encloses SCM anteriorly and trapezius posteriorly Pretracheal Layer surrounds the strap muscles and the viscera (larynx, thyroid, trachea, esophagus, sternohyoid, sternothyroid, tyrohyoid, and omohyoid) Prevertebral Layer surrounds the cervical vertebra and the neck ms.

Carotid Sheath formed by contributions from the 3 layers of the deep cervical fascia

Posterior Triangle Anterior: SCM Inferior: Clavicle Posterior: Trapezius

envelops the IJV, Common Carotid Artery (CCA), and CN X 1. Occipital Triangle Boundaries: SCM; omohyoid; trapz Floor: Semispinalis, splenius; levat. scap; scal. post; scal. med Contents: CN XI;( spinal accessory) lymph nodes; lesser occip. nerve; post. ext. jug v. Supraclavicular Triangle

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Boundaries: Floor: Contents:

Contains:

SCM; omohyoid; clavicle Scalenus ant. and sc. medius Subclavian art. Subclavian vein Subclavian lymph trunk Supraclavicular lymph nodes Transv. cervic. Art./V Suprascap. art./V Ventral rami of brachial plx (C5-C8) Scalene triangle Muscles of the Neck

SCM O: upper part of manubrium (stomal head) and medial third of the clavicle (clavicular head) I: mastoid process A: tilt head and face upward and to the opposite side, inspiration (muscle acts towards the origin) Innervation: CN XI (motor) and C2, C3 (sensory) Trapezius O: external occipital prutberance and superior nuchal line I: lateral third of the clavicle and acromion A: shoulder shrug, elevation and rotation of scapula and clavicle Innervation: CN XI (motor) and C3-C4 (sensory) Strap/Ribbon ms. All strap ms are attached to the hyoid bone on one end A: elevate the hyoid bone Suprahyoid ms depress hyoid bone Infrahyoid ms

Draining Patterns: Level IA: Floor of the mouth Anterior oral tongue Anterior mandibular alveolar ridge Lower lip Level IB: Level II: Oral cavity Anterior nasal cavity Soft tissue structures of the mid face Submandibular gland Oral cavity Nasal cavity Nasopharynx Oropharynx Hypopharynx Larynx Parotid glands

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Suprahyoid ms. located above the hyoid bone , thus elevate hyoid Posterior belly of digastric from mastoid bone Anterior belly of digastric from the inner surface of the mandible Digastrics open the jaw when the masseter and temporalis are relaxed Stylohyoid styloid process; elevates hyoid during swallowing Mylohyoid from the mylohyoid line (mandible); raise the oral cavity and hyoid, depress the mandible Geniohyoid from the inferior mental spine (symphysis menti); carries the hyoid and tongue upward during deglutition Infrahyoid ms. located below the hyoid bone, thus depress hyoid Sternohyoid from sternum (manubrium) Sternothyroid from sternum to the thyroid cartilage (the only one not connected to the hyoid bone); elevates the larynx, may slightly depress the hyoid Thyrohyoid from thyroid cartilage Omohyoid from the scapula; carries hyoid bone backward and to the side, depress the larynx and hyoid Cervical Lymphatics

CN XI is used as a landmark to subdivide group IIA and IIB as it travels obliquely across the area. IIA area that lies anteroinferiorly and closer to the IJV IIB area above and behind the nerve Level III: Level IV: Level V: Oral cavity Nasopharynx Oropharynx Hypopharynx Larynx Cervical esophagus Larynx Hypopharynx Thyroid Cervical esophagus Nasopharynx Oropharynx Cutaneous structures of the posterior scalp and neck

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Subdivided by the inferior border of the cricoid cartilage VA contains nodes associated w/ CN XI VB contains the transverse cervical and supraclavicular nodes Level VI: Thyroid gland Glottis and subglottic larynx Apex of the pyriform sinus Cervical esophagus

Surgical Level Approach: Level 1 Submental / Submandibular nodes Level 2 Upper Jugular Nodes Level 3 Middle Jugular Nodes Level 4 Lower Jugular Nodes Level 5 Posterior Triangle Nodes Level 6 Anterior Compartment Nodes Sublevel Division of the Neck Levels: IA Submental Group IB Submandibular Group IIA & IIB Upper Jugular Group (IIA alongside the jugular, IIB at the are of the mastoid) separated by CN XI III Mid Jugular Group IV Lower Jugular Group VA & VB Posterior Triangle Group (VA area of the occipital triangle, VB area of the supraclavicular triangle) separated by omohyoid VI Central or Anterior Group Specialized Area of Responsibility

Not routinely excised in the radical neck dissection; most commonly removed in surgeries for thyroid, laryngeal, and hypopharyngeal cancers

Nodes include: Paratracheal nodes (in the tracheoesophageal groove) Pretracheal Parathyroidal nodes (aroud the thyroid) Precricoid or Delphian node (on the cricoids membrane)

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Work-up of Assymetric, Unilateral Nodal Neck Mass Complete repeated PE of the ff: Oral cavity Nasopharynx Hypopharyx Larynx Thyroid Salivary glands Skin of the neck

Do indirect laryngoscopy, post rhinoscopy, oral cavity examination,.

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Fine Needle Biopsy 10cc syringe, gauge 23 or 25 needle,puncture the mass then aspirate, put it on s slide, and send to histopath for cell cytology Imaging chest xray, upper aerodigetive tract, rigid endoscope (office procedure)

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Panendoscopy with guided biopsy based on the location of the nodal mass Open biopsy of the cervical mass last step, super invasive If you do this, there is a possibility of spread of the tumor to the surrounding tissue end

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