1. Anatomy of the Neck

2. Anterior triangle Midline of the neck Sternocleidomastoid muscle
Lower border of the mandible

3. Subunits of ant. triangle
Submandibular triangle
Submental triangle
Carotid triangle
Muscular triangle

4. Submandibular triangle
Anterior & posterior bellies of digastric muscle
Lower border of the mandible

5. Submental triangle
Anterior bellies of the digastric muscle
Hyoid bone

6. Posterior triangle Anterior border of the trapezius m. SCM
Middle third of the clavicle

7. Subunits of post. Triangle
Subclavian triangle
Occipital triangle

8. Fascial layer of the neck
The cervical fascia represents a condensation of connective tissue that extends between anatomic structures

9. Superficial Fascia Lies just below the dermis
Deep portions of this layer encase the platysma muscle as well as the voluntary muscles of the face & scalp

10. Deep cervical fascia
Superficial layer
Middle layer
Deep layer

11. Superficial layer of deep cervical fascia
Begins from the vertebral spinous processes and splits to enclose the trapezious
Again it splits to invest SCM as well as strap muscle
Superior attachment : occipital protuberance , superior nuchal line & zigomatic arch

12. Between parotid & submandibular glands the two layer rejoin to form the stylomandibular ligament
Inferiorly the fascia split and attach to the anterior and posterior surface of the sternum : Suprasternal space of Burns

13. Middel layer of the deep cervical fascia
It encloses the thyroid gland , trachea , pharyngeal constrictor muscle & esophagus
It extends from the hyoid bone down to the sternal attachments and is continuous with fibrous pericardium

14. Deep layer of the deep cervical Fascia
Anterior to the vertebral bodies
Tips of transverse process
Vertebral spines posteriorly
From the skull base until the coccyx

15. Prevertebral layer
Alar layer ( until first thoracic vertebra )

16. Danger space
A potential space is created between the alar and prevertebral fascias because it communicates directly with the mediastinum

17. Prevertebral space
Between the prevertebral fascia and vertebral body

18. Retropharyngeal space
Between alar and the visceral fascia

19. Tissue space of the neck
Between cervical fascia exist potential spaces

20. Because superficial and deep layers of the deep cervical fascia fuse at the hyoid bone infection in the spaces above the hyoid does not spread directly to spaces below the hyoid

21. Communication along the entire length of the neck occurs posteriorly along the retropharyngeal and prevertebral spaces .

22. Submandibular space
Between outer space of of mylohyoid muscle and superficialstructure within submandibular triangle
Along the posterior free edge of the mylohyoid muscle it continuous with the sublingual space
It also communicate with submental and contralateral submandibular space `

23. Intrapharyngeal space
Inner surface of the superior constrictor muscle and the pharyngeal mucosa
It also known as peritonsillar space

24. Parapharyngeal space Medial : superior constrictor m.
Lateral : pterygoid muscles and fascia of the parotid gland
Inferior : Fascial attachment to the hyoid

25. Posteromedially this space communicates with the retropharyngeal space providing a route to spread infection

26. Retropharyngeal space
Entire length of the neck
Between visceral fascia and alar fascia
From the skull base down to the T1

27. Danger space Between alar fascia and prevertebral fascia
Retropharyngeal space→ danger space →mediastinum

28. Prevertebral space Between prevertebral fascial and vertebral column
From the skull base to the lower thoracic area

29. Artery of the neck

30. Common carotid artery Right side from brachiocephalic artery
Left side from aortic arch
It crosses by omohyoid muscle , , superior & middle thyroid vein

31. Internal carotid artery
it crosses by hypoglossal nerve , occipital artery & posterior belly of digastric muscle
Near skull base it crosses by glossopharyngeal nerve ,stylohyoid , stylopharyngeous ,styloglossus muscle and styloid process

32. External carotid artery
It crosses superficially to styloglossus and stylopharyngeous muscle
Terminal branches passing behind the condylar process

33. Superior thyroid artery
At the level of greater horn hyoid bone
Superior part of thyroid gland , larynx and SCM

34. Ascending pharyngeal artery
At the level of sup. Thyroid artery posteriorly
Supply pharynx , palate , tonsil , middle ear and meninges

35. Lingual artery Above the superior thyroid artery
Runs anterior and superior
Passes beneath the hyoglossus muscle to enter the tongue

36. Facial artery
On the anterior surface of carotid , deep to the digastric muscle
Passes through the submandibular gland , crosses the inferior border of the mandible
Branches in the neck : ascending palatine artery , tonsillar artery , branches of the submandibular gland , submental artery

37. Occipital artery
From posterior surface of the external carotid artery the hypoglossal nerve hooks around it
Supply suboccipital region of the scalp , SCM , digastric and stylohyoid muscle

38. Posterior auricular artery
Posteriorly at the level of the upper border of digastric muscle
Passes between the mastoid and ear
Branches to the parotid gland , auricle and scalp

39. Terminal branches Superficial temporal : toward the scalp
Maxillary artery : infratemporal fossa → pterygopalatine fissure → pterygopalatine fossa

40. Thyrocervical thrunk
Arises from the first part of the subclavian artery just anterior to the scalenus anrerior muscle
Transverse cervical branch → SCM , trapezius
Inferior thyroid artery : deep to the carotid sheath
Supply inferior portion of the thyroid , sup. & inf. Parathyroid gland and a portion of larynx and trachea
Inter the thyroid at the level of cricoid

41. Vein of the neck

42. Internal jugular vein
Sigmoid sinus → intrenal jugular vein → subclavian vein
Major tributaries :inferior petrosal sinus
Common facial vein
lingual vein
superior thyroid vein
middle thyroid vein

43. External jugular vein
Posterior auricular vein + posterior branch retromandibular vein
Deep to the platysma but superficial to the SCM
Terminate in the subclavian vein
At its midportion it joined by posterior external jugular vein

44. Anterior jugular vein
Confluence of the vein in the submandibular region
Drain to the external jugular or subcalavian vein

45. Nerve of the neck

46. Glossopharyngeal nerve
Sensory , motor , parasympathic component
It has superior and inferior ganglion
Anterior to the internal and deep to the external carotid artery
Pass between superior and middle constrictor muscle
Innervate tonsil , pharynx and tongue

47. Tympanic nerve Arises from inferior ganglion
Tympanic canaliculus → middle ear (jacobson nerve )
Sensory fiber to the middle ear , eustachian tube and mastoid cavity

48. Lesser petrosal nerve Preganglionic parasympathetic fibers
Tympanic plexus → floor of middle cranial fossa → foramen oval → infratemporal fossa → otic ganglion
In the otic ganglion it synapsis with postganglionic fiber of parasympathic that supply the parotid gland

49. Carotid branch Arises from IX nerve just below the skull base
Unit with carotid branch of vagus nerve and carries sensory information back from the carotid body and carotid sinus

50. Pharyngeal branch
Reach to the pharyngeal plexus on the middle constrictor muscle
Sensory innervation

51. Stylopharyngeus branch
Only motor branch of the IX nerve
Supply stylopharyngeal muscle

52. Tonsilar branch Form a plexus with the lesser palatine nerve
Supply tonsil and soft palate

53. Lingual branch
Taste and general sensation to the posterior 1/3 tongue

54. Vagus nerve

55. Superior and inferior ganglion at the jugular foramen
Sensory , motor and parasympathetic fibers

56. Superior ganglion branches
Meningeal branch( posterior cranial fossa )
Auricular branch (pinna, EAC, TM )

57. Superior ganglion branch
Pharyngeal branch ( pharynx and palate )
Superior laryngeal nerve
Right RLN : in front the subvlavian a.
Left RLN : in front the aortic arch

58. Accessory Nerve

59. Cranial component : sensory
Join the vagus nerve
pharyngeal plexus
Spinal component : motor ( C2 – C4 )
lateral to IJV
emerge 1 cm above Erb point

60. Hypoglossal nerve
Occipital bone → under posterior belly digastric → looping around occipital a.→
across carotid arteries → deep to the submandibular gland → on the surface of hyoglossus muscle
Innervation : interinsic muscle of tongue , styloglossus , hyoglossus , genioglossus

61. Ansa cervicalis Motor innervation to the strap muscle
Upper branch : hypoglossus nerve
Lower branch : C2 , C3 from the cervical plexus

62. Cervical sympathetic trunk
Thoracic spinal cord → sympathetic cervical ganglia →
Superior cervical ganglia ( at the level of the C2 & C3 behind the carotid sheath
internal carotid nerve passes into carotid canal → internal carotid plexus

63. Cervical sympathic (cont )
Middle cervical ganglia :
At the level of C6
Inferior cervical ganglia :
in the root of the neck

64. Cervical plexus From C1 – C6 Motor & sensory nerve
Phrenic nerve (motor br : C3,C4,C5 )
Sensory br : lesser occipital nerve
greater auricular nerve
Anterior cutaneous nerve
supraclavicular nerve

65. Lymphatics of the neck Superficial group : submental submandibular
superficial cervical
anterior cervical
Deep group : pretracheal ,
paratracheal
perithyroid
retropharyngeal

66. The node of Rouviere refers to the highest retropharyngeal lymph node which is adjacent to the jugular foramen

67. Compartment of the neck

68. Level I Posterior belly of the digastric muscle Body of the mandible
Hyoid bone

69. Submandibular nodes Preglandular Postglandular Prevascular
Postvascular
Intracapsular

70. Drainage
Upper & lower lip , Cheek skin , nasal skin & mucosa , medial canthus , anterior alveolus , anterior tonsillar pillar soft palate , 2/3 anterior of the tongue , submandibular salivary gland
Drain into upper internal jugular nodes

71. Submental nodes 2-8 nodes Between anterior belly of digastric muscle
Mylohyoid platysma
Drain mentum , midportion of the lower lip , anterior alveous , anterior 1/3 of the tongue
Second drainage to ipsilat. & contralat. preglandular or prevascular submandibular nodes or IJV

72. Level II Base of the skull → carotid bifurcation or hyoid bone
Posterior border of SCM → lateral border of sternohyoid muscle

73. Level III
Carotid bifurcation to the omohyoid muscle or cricothyroid notch

74. Level IV
Along the inferior 1/3 of the IVJ from the omohyoid to the clavicle

75. Level V
From the anterior border of the trapezius m. to the posterior border of SCM and the clavicle inferiorly

76. Level VI Surrounded midline visceral structure
From the hyoid bone to the sternal notch
The lateral border is the carotid sheath
Consists of paratracheal node , perithyroid nodes , precricoid ( Delphian ) nodes and nodes along the RLN

77. Level VII
The upper mediastinal lymph node and inferior to the suprasternal notch

78. Anterior nodal group Anterior jugular chain
Juxtavisceral chain : prelaryngeal
prethyroid
pretracheal
paratracheal

79. Prelaryngeal : supraglottis
Prethyriod : infraglottic , thyroid isthmus , anteromedial thyroid lobe
Pretracheal node : from thyroid isthmus to the innominate vein ,2-12 node ,thyroid gland and trachea
Paratracheal : lateral aspect of thyroid & parathyroid gland , postcricoid , trachea, esophagus

80. Lateral group Superficial chain : related to EJV
drain to transverse cervical

81. Deep group Spinal accessory chain Transverse cervical chain
Internal jugular chain

82. Spinal accessory chain : up to 20 nodes
Transverse cervical chain : 12 nodes
Internal jugular chain : 30 nodes
on left side : thoracic duct
on right side : right lymphatic duct

83. Sublingual nodes
Along collecting trunk of the tongue & sublingual gland
Drain anterior floor of the mouth & ventral surface of the tongue
Connect to the submandibular group or upper IJ chain

84. Parotid Nodes
Extraglandular group : preauricular & infraauricular nodes
Drain lateral and frontal aspects of the scalp, anterior auricle , external auditory canal , skin of the lateral face , buccal mucosa
Intraglandular nodes : drain the same side

85. Retropharyngeal node Between pharyngeal wall and prevertebral fascia
Lateral group : 1-3 nodes at the level of C1
Medial group : to the level of the cricoid
Drain nasal cavity,sphenoid sinus, ethmoid sinus,hard & soft palate, nasopharynx & posterior pharyngeal wall

86. The retropharyngeal space can be accessed by rotating the pharynx medially and opening the infected tissue between the pharynx and cervical spine

87. Occipital nodes Superficial group : 2-5 nodes
Between SCM & trapezius m. at apex of posterior triangle , superficial to the splenius m. & deep to investing fascia
Drain occipital scalp , posterior cervical skin → deep group → upper spinal accessory

88. Postauricular nodes
1-4 nodes over fibrous insertion of SCM on the mastoid tip
Drain posterior parietal scalp , skin of mastoid and postauricular area → infraauricular parotid LN

89. Cont.
Deep group : 1-3 nodes deep to the splenius m. along the course of the occipital artery
Drain the deep musculature of the neck in occipital region→ INJ & spinal accessory nodes

90. Thoracic duct
Passes up through mediastinum → left root of the neck → posterior to the carotid sheath & medial to the anterior scalene m.
It empties through multiple branches into the lowest portion of the IJV , the subclavian vein or both
Main duct may extend as high as 5 cm above the clavicle