1. Anatomy of the neck and nerve supply of the lower neck
Shahd Hassan Ahmed- 2016D037
Shaik Zahra Fatima- 2016D044
Akshara Gaurav Kaushik- 2016D055

2. Contents Deep cervical fascia Cervical vertebrae
Arteries and veins of the neck
Nerve supply of the neck
Muscles of the neck
Pharynx
Larynx
Thyroid gland

3. The Deep Cervical Fascia
The deep cervical fascia of the neck is composed of 4 layers. From outside inwards these are as follows:

4. The Investing fascia ( most superficial layer)
It contains the trapezius and sternocleidomastoid muscles. It also splits to enclose the parotid and submandibular gland.
It has the following attachments:
Inferiorly: Manubrium of sternum, spine of the scapular, acromion process and the clavicles.
Superiorly: Superior nuchal line of the occipital bone, external occipital protuberance, mastoid processes of the temporal bones, zygomatic arches, base of mandible
Anteriorly: Hyoid bone and symphysis menti
Posteriorly: continuous with the periosteum covering the C7 spinous process, and with the ligamentum nuchae.

5. The Pretracheal fascia
It can be anatomically divided into two parts:
Muscular – encloses the infrahyoid muscles.
Visceral – encloses the thyroid gland, trachea and oesophagus.
Attachments:
Posteriorly: Continuous with the buccopharyngeal fascia of the pharynx, and laterally with the carotid sheaths.
Superiorly: Hyoid bone and oblique line of the thyroid cartilage
Inferiorly: Passes in front of trachea to blend with arch of aorta.

6. The Prevertebral fascia
It has the following attachments:
Superiorly: Attaches to the base of the skull
Anteriorly: Attaches to the transverse processes and vertebral bodies of the vertebral column
Posteriorly: Attaches along the ligamentum nuchae
Inferiorly: It descends down to superior mediastinum and blends with T3

7. Carotid sheaths
The carotid sheaths are paired structures which enclose important vessels and nerves.
The contents of the carotid sheath are:
Common and internal carotid arteries
Internal jugular vein
Vagus nerve
Deep cervical lymph nodes
Carotid sinus nerve
Sympathetic nerve fibres

8. Potential facial spaces
Loose areolar tissue fills the spaces between the various layers of the deep cervical fascia.
There are two important facial spaces to consider:
Retropharyngeal space:
It is posterior to the pharynx and oesophagus, and extends from the base of the skull to a variable level between the T1 and T6 vertebral bodies.
Contents: Areolar fat, lymph nodes (above hyoid), small vessels
Alar (danger) space:
A subdivision of the retropharyngeal spaces created by the alar fascia. It extends from the base of the skull above to the superior mediastinum below. It is also called the danger space.

9. Clinical question
A 5-year-old boy presents to the ED with fever, neck pain, drooling and a muffled voice. On physical exam, cervical lymphadenopathy and a posterior pharyngeal wall mass is noted.
What is your diagnosis?
Ludwig's angina
Retropharyngeal Abscess
Acute necrotizing mediastinitis
Cushings syndrome

12. Jugular lymph Trunk Efferent:
On the left side: it ends in the thoracic duct.
On the right side: it ends in the right lymphatic duct

13. Cervical vertebrae
In vertebrae, cervical vertebrae are the vertebrae of the neck which is immediately below the skull. Cervical vertebrae are of two types:-
Typical vertebrae : which shares the same criteria (3rd, 4th, 5th, 6th)
Atypical vertebrae : which is different from the typical vertebrae. (1st,2nd,7th)

14. Typical vertebrae
It consist of the body which is small and kidney shaped and the superior and inferior part of the body is related to the intervertebral disc.
The spine is directed posteriorly and is bifid (splitted).
Transverse process is short and is pierced by foramen transverium for the vertebral artery.
Vertebral arch encloses the vertebral foramen for the spinal cord. It consist of 2 lamina, 2 pedicles and 2 superior and inferior articular facet.

15. Atypical cervical vertebrae
Vertebrae prominence
It is the 7th cervical vertebrae which is same as the typical vertebrae except the spine.
The spine in the 7th cervical vertebrae is no bifid, is long and can be felt subcutaneously in the back of the neck.
The foramen trasversarium gives passage to the vertebral vein.

16. Atlas It is the first cervical vertebrae which has no body and spine.
It consist of the narrow anterior arch (attachment to anterior atlanto-occipital membrane) which carries anterior tubercle (attachment to anterior longitudinal ligament) and the inner surface of the anterior arch, caries articular facet for the dens of axis.
Posterior arch (attachment to posterior atlanto- occipital membrane) which caries posterior tubercle (attachment to ligamentum nuchae) and vertebral groove.

17. Lateral mass includes superior (kidney shaped) and inferior (rounded) articular facet and medial tubercle (attachment to the transverse ligament of atlas).

18. Axis
It is the second cervical vertebrae which consist of the body, has an upward projection which is called dens (odontoid process)
Dens, anteriorly it articulate with the atlas in the median atlanto-axial joint (pivot).
Apex gives attachment to the apical ligament and sides for the alar ligament.

19. Body gives attachment anteriorly -> anterior longitudinal ligament
posteriorly -> posterior longitudinal ligament
Spine gives attachment to ligamentum nuchae.
Lamina gives attachment to the ligamentum flavum.

20. Clinical question
A 21-year-old, fit and healthy football player was tackled from behind while running with the ball. He lost his balance and landed on his head/neck . This result in  a severe, sudden twist to the neck & a severe blow to the head & neck area, the patient present with severe pain, bruising and swelling at the back of the neck & dizziness .
What is your diagnosis?
Arthritis
Cervical vertebrae fracture
Muscle tension and strain
Osteoporosis

21. Major Blood Vessels of the Neck
Arch of Aorta
Branches of Arch of Aorta
1. Left Subclavian artery.
2. Left Common Carotid artery.
3. Brachiocephalic trunk.
Aorta

22. Common Carotid Artery Relations Skin, fascia Sterocledomastoid
Sternohyoid
Sternothyroid
Superior belly of omohyoid
Antrolaterally
Transverse process of the lower 4 cervical vertebrae
Prevertebral muscles
Sympathetic trunk
Vertebral vessels
Posteriorly
Larynx pharynx,
Trachea esophagus
Lobe of thyroid gland
Medially
Internal jugular vein
Vagus nerve
Laterally
Each common carotid gives two branches:
Internal carotid
External carotid

23. External Carotid Artery
Arises just below
the hyoid bone &Ends in
the thyroid gland.
Supplies thyroid gland.
It divides behind neck of the mandible into two 2 terminal branches:
Superficial temporal
Maxillary artery
It supplies:
Scalp: Superficial temporal artery
Face: Facial artery
Maxilla: Maxillary artery
Tongue: Lingual artery
Glands: Superior thyroid artery
The smallest branch
Of the external carotid.
Supplies pharynx.

24. Internal Carotid Artery
Subclavian Artery
Left subclavian arises
from aortic Arch.
Right subclavian arises
From brachiocephalic
trunk.
Subclavian arteries give
contribution to CNS
through one of its main
branches; Vertebral artery
( Supply CNS)
Internal Carotid Artery
Arises from the common carotid at the level of the superior border of the thyroid cartilage
It Supplies:
Brain
Nose
Scalp
Eye

25. Internal Jugulars vein
External Jugular vein
VEINS oF THE NECK
Anterior jugular vein
Just above the sternum
the two anterior jugular
veins communicate by a
transverse vein to form
the Jugular arch.
Receives drainage thyroid
And pharynx
It passes down
the neck and it is
the only tributary
of the subclavian
vein.
Internal Jugulars vein
Superior Vena Cava
Joins the subclavian vein to
form The brachiocephalic
vein.
Tributaries:
Superior thyroid
Lingual
Facial
Occipital veins
Dural venous sinuses
Formed by the union of the right and left brachiocephalic veins.
Drains venous blood from:
Head, neck, thoracic wall & upper limbs
It Passes downward and enter
the right atrium.

26. Nerves of The Neck I. Cervical plexus: Formation:
Lesser occipital nerve (the skin behind the auricle up to external protuberance)
Cutaneous branches:
Formation:
– Formed by anterior rami of C1 - C4 spinal nerves.
Position:
– Lies in front of levator scapulae and scalenous medius and deep to the superior part of the sterno – cleido –mastoid.
Great auricular nerve (the angle of the mandible).
Transverse cervical nerve of neck (antero - lateral part of the neck).
Supraclavicular nerve (the upper part of the chest).
Phrenic nerve: (anterior rami of C3 - C5):
– Supplies diaphragm (motor and sensory) and
pericardium.
B. Muscular branches:
Supply the deep muscles of neck.
Ansa cervicalis:
– Hypoglossal nerve gives off superior root of ansa (descendens hypoglossi), composed of fibers from nerve C1.
– Joins inferior root of ansa (descendens
cervicalis, C2 and C3) to form a loop, the ansa cervicalis, which supplies infra -hyoid
muscles.

27. II. Vagus nerve: Internal laryngeal nerve: Pierces thyro - hyoid
membrane to innervates mucous membrane of
larynx above vocal cord.
Superior laryngeal nerve:
– Leaves skull via jugular foramen.
– Descends in the neck in carotid sheath between
internal (or common) carotid artery medially
and internal jugular vein laterally.
External laryngeal
nerve: Innervates crico –
thyroid muscle.
2. Cervical cardiac branches
3. Recurrent laryngeal nerves:
– Ascends in tracheo - esophageal groove.
– Enters larynx posterior to crico - thyroid joint, the nerve is now called inferior laryngeal
nerve.
– Innervations: laryngeal mucosa below vocal
cords, all laryngeal muscles except crico - thyroid .

28. V. Cervical part of sympathetic trunk:
III. Accessory nerve:
V. Cervical part of sympathetic trunk:
– Supplies sterno - clido – mastoid And trapezius muscle.
Formed by superior
situated in front of transverse processes of C1 - C3 vertebra.
Superior cervical ganglion:
situated at the level of transverse processes of C6
Middle cervical ganglion:
– Is situated at level of C7
vertebra, and may be
fused with first thoracic
ganglion to form cervico
- thoracic ganglion or
stellate ganglion
Inferior cervical ganglion:
IV. Hypoglossal nerve:
– Supplies muscles of
tongue except
palatoglossus.

29. Muscles

30. Sternocleidomastoid –
Platysma –
Origin- subcutaneous tissue of infraclavicular and supraclavicular regions
Insertion- base of mandible; skin of cheek and lower lip; angle of mouth; orbicularis oris
Actions- Draws the corners of the mouth inferiorly and widens it (as in expressions of sadness and fright). Also draws the skin of the neck superiorly when teeth are clenched
Sternocleidomastoid –
Origin- Manubrium and medial 1/3 of the clavicle
Insertion- Mastoid process of the temporal bone, superior nuchal line
Actions- Unilaterally: contralateral cervical rotation, ipsilateral cervical flexion , Bilaterally: cervical flexion, elevation of sternum and assists in forced inhalation.
Trapezius
Origin- Superior nuchal line, external occipital protuberance, ligamentum nuchae, spines of C7 to T12 and their supra-spinous ligaments
Insertion- Spine of the scapula, acromion, lateral 1/3 of clavicle
Actions- Rotation, retraction, elevation, and depression of scapula

31. Clinical question
A 28-year-old male boxer was punched in the face, the patient shows variety of symptoms including head and face pain, balance problems, visual disturbances, ear and sinus symptoms, and inability to contralaterally rotate and ipsilaterally flex the neck with difficulties in inhalation .
Which of the following muscles is injured ?
Omohyoid muscle
Superior- constrictor
Sternocleidomastoid
Zygomaticus major muscle 

32. Deep cervical (prevertebral) muscles
Longus capitis
Origin- Anterior tubercles of transverse processes of cervical 3-6 vertebrae
Insertion- Inferior surface of basilar part of occipital bone
Action- Flexes the head
Rectus capitis anterior
Origin- Anterior surface of lateral mass of atlas in front of the occipital condyle
Insertion- Basilar part of the occipital bone
Action- Flexes the head
Longus colli
Origin- Upper oblique part: Anterior tubercles of the of transverse processes of C3, C4 & C5
Lower oblique part: Bodies of upper 2-3 thoracic vertebrae
Middle vertical part: Bodies of upper 3 thoracic and lower 3 cervical vertebrae
Insertion- Upper oblique part: anterior tubercle of atlas
Lower oblique: Anterior tubercles of transverse processes of 5th & 6th cervical vertebrae
Middle verticle part: Bodies of 2,3,4 cervical vertebrae
Action-Flexes the neck, Oblique parts flex the neck laterally, Lower oblique part rotates the neck to the opposite side
Rectus capitis lateralis
Origin- Upper surface of transverse process of atlas
Insertion- Inferior surface of jugular process of the occipital bone
Action- Flexes the head laterally

33. Infrahyoid muscles Omohyoid
Origin- Inferior belly: Superior border of scapula
Superior belly: Intermediate tendon
Insertion- Inferior belly: Intermediate tendon
Superior belly: lower border of body
of hyoid bone
Action-Depresses hyoid bone and larynx
Thyrohyoid
Origin-Oblique line of thyroid cartilage
Insertion- Lower border of body and greater horn of hyoid bone
Action- Depresses the hyoid bone
Sternohyoid
Origin-Posterior border of manubrium sterni, adjoining parts of clavicle and sternoclavicular ligament
Insertion- Medial part of lower part of hyoid bone
Action-Depresses hyoid bone and larynx
Sternothyroid
Origin- Posterior aspect of manubrium sterni, Adjoining part of 1st coastal cartilage
Insertion- Oblique line of thyroid cartilage
Action- Depresses the larynx

34. Posterior belly of digastric Anterior belly of digastric
Suprahyoid muscles
Mylohyoid
Origin- Mylohyoid line on medial aspect of mandibular body
Insertion- Median raphe and body of hyoid bone
Action- Elevates hyoid bone, base of tongue and floor of mouth
Geniohyoid
Origin- Inferior genial tubercle of mandible
Insertion- Body of hyoid bone
Action- Elevates hyoid bone, protracts hyoid bone
Stylohyoid
Origin- Styloid process
Insertion- Greater horn of hyoid bone
Action- Elevates hyoid bone
Posterior belly of digastric
Origin- Digastric notch of temporal bone at base of skull
Insertion- Intermediate tendon
Action- Raises hyoid bone
Anterior belly of digastric
Origin- Intermediate tendon
Insertion- Digastric fossa of mandible
Action- Elevates hyoid bone

35. Scalene muscles Middle scalene
Origin: Posterior tubercles of the transverse processes of (C2-C7) Insertion: Cranial surface of the first rib Action: Flexion of the cervical spine, Lateral flexion of cervical spine
Anterior scalene
Origin: Anterior tubercles of the  transverse processes of (C3-C6) Insertion: Scalene tubercle and cranial crest of first rib Action: Flexion of the cervical spine, Lateral flexion of the cervical spine
Posterior scalene
Origin: By tendons from the posterior tubercles of  the transverse processes of (C4–C6) Insertion: Outer surface of 2nd rib Action: Lateral flexion of the neck

36. Pharynx
Pharynx is a musculo - membranous tube which lies behind the nose, mouth and larynx. It has no anterior wall , so that the pharynx can communicate freely with 3 cavities. Arterial Blood Supply: Ascending pharyngeal artery, Ascending palatine and tonsillar arteries, maxillary artery and lingual artery. Venous Drainage: Pterygoid venous plexus and I.J.V.

37. External layer of muscles of the pharynx
Superior- constrictor
Origin: Pterygoid hamulus, pterygomandibular raphe, posterior end of mylohyoid line of mandible, and side of tongue
Insertion: Median raphe of pharynx and pharyngeal tubercle on basilar part of occipital bone
Middle- constrictor
Origin: Stylohyoid ligament and superior(greater) and inferior(lesser) horns of hyoid bone
Insertion: Median raphe of pharynx
Inferior- constrictor
Origin: Oblique line of thyroid cartilage and side of cricoid cartilage
Insertion: Median raphe of pharynx
Action of the muscles : Constrict wall of pharynx during swallowing

38. Inner layer of muscles of the pharynx
Salpingo-pharyngeus
Origin: Cartilaginous part of pharyngotypanic tube
Insertion: Blends with palatopharyngeus
Palato-pharyngeus
Origin: Hard palate and palatine aponeurosis
Insertion: Posterior border of lamina of thyroid cartilage and side of pharynx and esophagus
Stylo-pharyngeus
Origin: Styloid process of temporal bone
Insertion: Posterior borders of thyroid cartilage with palatopharyngeus
Action of the muscles: Elevate(shorten and widen) pharynx and larynx during swallowing and speaking

39. Larynx
The larynx is a hollow musculo – ligamentous structure with a cartilaginous framework.
Above the vocal cords
Below the vocal cords
Arteries
Superior laryngeal Artery
Inferior laryngeal Artery
Veins
Superior laryngeal Vein
Inferior laryngeal Vein
Lymphatics
Upper deep cervical lymph nodes.
Lower deep cervical lymph nodes.
Sensory nerve supply to the mucosa
Internal laryngeal Nerve
Recurrent laryngeal Nerve
Motor nerve supply
All muscles are supplied by recurrent laryngeal nerve except crico- thyroid muscle which is supplied by external laryngeal nerve

40. Posterior cricoarytenoid
Muscles of the larynx
Transverse arytenoid
Origin: Posterior surface of one arytenoid
Insertion: Posterior surface of another arytenoid
Action: Adductor of vocal cords
Oblique arytenoid and aryepiglottic
Origin: Muscular process of one arytenoid
Insertion: Apex of the other arytenoid
Action: Adductor of vocal cords
(Aryepiglottic-Closing inlet of larynx)
Cricothyroid
Origin: Cricoid cartilage
Insertion: Thyroid cartilage.
Action: Elongates and tenses of vocal cords
Posterior cricoarytenoid
Origin: Posterior surface of cricoid
Insertion: Posterior aspect of muscular process of arytenoid
Action: Abductor of vocal cords

41. Thyroarytenoid and thyroepiglottic
Origin: Inner surface of thyroid cartilage
Insertion: Anterolateral surface of arytenoid cartilage
Action: Relaxor of vocal cords
(Thyroepiglottic- Opening inlet of larynx)
Lateral cricoarytenoid
Orgin: Front of cricoid
Insertion: Front of muscular process of arytenoid
Action: Adductor of vocal cords
(Aryepiglottic-Closing inlet of larynx)
Vocalis
Origin: Vocal process of arytenoid cartilage
Insertion: Vocal ligament
Action: Relaxor of vocal cords

42. Thyroid gland
Thyroid gland is a highly vascular endocrine gland which has inner capsule and outer capsule.
It is supplied by superior thyroid artery, inferior thyroid artery and thyroid ima artery
It’s venous drainage includes superior, middle and inferior thyroid veins.
It is innervated by superior, middle and inferior cervical sympathetic ganglia.

43. Clinical question
A 42 year old man visited the doctor and complained of heat intolerance, increased bowel frequency and insomnia. He presented with exophthalmos, pretibial myxedema and thyroid bruits. Examination revealed warm, moist skin, goiter and hyperactive reflexes. Laboratory reports reveal raised levels of T4 hormone.
What is your diagnosis? How can it be treated?
Hypothyroidism a) Total thyroidotomy
Hyperthyroidism b) Levothyroxine
Addison’s disease c) B-blockers
Cushing's syndrome d) Glucocorticoids