Neck 山东大学医学院 解剖教研室 李振华

The muscles of neck Superficial group Platysma 颈阔肌，a thin sheet-like muscle of facial expression Sternocleidomastoid 胸锁乳突肌

Suprahyoid muscles Elevate (raise) hyoid bone and depress mandible. Digastric 二腹肌 Stylohyoid 茎突舌骨肌 Mylohyoid 下颌舌骨肌 Geniohyoid 颏舌骨肌 Elevate (raise) hyoid bone and depress mandible.

Infrahyoid muscle Depress hyoid or larynx after elevation Sternohyoid 胸骨舌骨肌 Sternothyroid 胸骨甲状肌 Thyrohyoid 甲状舌骨肌 Omohyoid 肩胛舌骨肌 Depress hyoid or larynx after elevation

Deep group Lateral Medial Flex the head, bends the neck forward Scalenus anterior 前斜角肌 Scalenus medius 中斜角肌 Scalenus posterior 后斜角肌 Medial longus capitis 头长肌 longus colli 颈长肌 Flex the head, bends the neck forward

Major muscles of the neck Sternocleidomastoid Origin: manubrium and sternal end of clavicle Insertion: mastoid process of temporal bone Action: contraction of one muscle draws head toward the same side, and turn face to opposite side; both muscles act together to draw head backward

Scalenus anterior Origin: transverse processes of C3-C6. Insertion: tubercle for scalenus anterior Action: unilateral, bends neck laterally; bilateral, elevate first rib, an accessory muscle of inspiration; if rib is fixed, flex neck anteriorly Scalene fissure 斜角肌间隙 Above the first rib, there is a triangular space between scalenus anterior and midius. The brachial plexus and the subclavine a. emerge from this space.

The arteries of neck Common carotid artery 颈总动脉 Origin (arises from) Brachiocephalic trunk on the right Aortic arch on the left Ascends in neck to upper border of thyroid cartilage; bifurcates into internal and external carotid arteries

Carotid sinus 颈动脉窦(baroreceptor), located at a localizes dilation of terminal part of common carotid artery or beginning of internal carotid artery, sensitive to blood pressure changes Carotid glomus 颈动脉小球 (chemoreceptor), lies posterior to the point of bifurcation of common carotid artery, senses changes in blood carbon dioxide (oxygen) levels

Branches of external carotid a. Superior thyroid a. 甲状腺上动脉－descends to supply upper pole of thyroid gland and larynx Lingual a. 舌动脉 Facial a. 面动脉 Occipital a.枕动脉 Posterior auricular a. 耳后动脉 Maxillary a. 上颌动脉 Superficial temporal a. 颞浅动脉

Subclavian artery 锁骨下动脉 Origin (arises from) Brachiocephalic trunk on right Aortic arch on left Becomes axillary artery at lateral border of first rib Branches Vertebral a. 椎动脉 Internal thoracic a. 胸廓内动脉 Thyrocervical trunk 甲状颈干 Inferior thyroid artery 甲状腺下动脉－supplies inferior pole of thyroid gland Costocervical trunk 肋颈干

Veins Draining the neck Internal jugular vein 颈内静脉 Begin at jugular foramen, descending to join the subclavian vein to form brachiocephalic vein Lies lateral first to internal and then to common carotid a. within carotid sheath Chief extracranial tributaries Common facial vein 面总静脉 Lingual v. 舌静脉 Pharyngeal v. 咽静脉 Superior thyroid v.甲状腺上静脉 Middle thyroid v. 甲状腺中静脉

Subclavian vein It is an continuation of axillary vein at the lateral border of first rib Joins internal jugular vein to form the brachiocephalic vein. Angle of union is termed venous angle 静脉角

External jugular vein 颈外静脉 Formed behind angle of mandible by union of posterior auricular, posterior branch of retromandibular and occipital vein Crossing sternocleidomastoid to enter subclavian vein Anterior jugular vein 颈前静脉 Drains submandibular and anterior neck regions Descends near midline, runs posterior to sternal end of sternocleidomastoid to drain into external jugular vein or subclavian vein

Lymph nodes of neck Anterior cervical lymph nodes Superficial anterior cervical lymph nodes Deep anterior cervical lymph nodes Lateral cervical lymph node Superficial lateral cervical lymph nodes－lie along the external jugular vein

Deep lateral cervical lymph nodes Extend along the internal jugular vein from the base of skull to the root of neck, divided into superior deep lateral cervical lymph nodes and inferior deep lateral cervical lymph nodes Receive lymphatic vessels from head, neck, tongue, larynx, cervical parts of esophagus and trachea, thyroid gland, upper parts of the thoracic wall and breast Efferent vessels form the jugular trunk－the left jugular trunk joins the thoracic duct and right may joint the right lymphatic duct

Superior deep lateral cervical lymph nodes 颈外侧上深淋巴结 Jugulodigastric lymph node 颈内静脉二腹肌淋巴结: lies at the junction of posterior belly of digastric and internal jugular vein Inferior deep lateral cervical lymph nodes 颈外侧下深淋巴结 Juguloomohyoid lymph node 颈内静脉肩胛舌骨肌淋巴结: lies at the junction of the intermediate tendon of omohyoid and internal jugular vein Supraclavicular lymph nodes 锁骨上淋巴结: lie along the subclavian artery

Right lymphatic duct 右淋巴导管 Formed by union of right jugular, subclavian, and bronchomediastinal trunks Ends by entering the right venous angle Receives lymph from right half of head, neck, thorax and right upper limb Thoracic duct 胸导管 At the roof of the neck, it turns laterally and arches forwards and descends to enter the left venous angle Just before termination, it receives the left jugular, subclavian and bronchomediastinal trunks

Cervical plexus Formation: formed by anterior rami of C1-C4 spinal nerves Position: lies in front of the origin of levator scapulae and scalenus medius and deep to the superior part of the sternocleidomastoid

Branches Cutaneous branches: emerge around middle of posterior border of sternocleidomastoid, to supply skin of neck and scalp between auricle and external occipital protuberance Lesser occipital n. 枕小神经 Greet auricular n. 耳大神经 Transverse nerve of neck 颈横神经 Supraclavicular n. 锁骨上神经

Muscular branches: supply the deep muscles of neck Phrenic nerve 膈神经(anterior rami of C3-C5) Lies on anterior scalene, deep to fascia To diaphragm (motor and sensory) Ansa cervicalis 颈袢: Hypoglossal nerve gives off superior root of ansa (descendens hypoglossi), composed of fibers picked up from nerve C1 Joins inferior root of ansa (descendens cervicalis, C2and C3) to form a loop, the ansa cervicalis, which supplies infrahyoid muscles

Vagus nerve (Ⅹ) Leaves skull via jugular foramen Descends in the neck in carotid sheath between internal (or common) carotid artery and internal jugular vein

Branches Superior laryngeal nerve 喉上神经 passes down side of pharynx and given rise to Internal branch 内支 which pierces thyrohyoid membrane to innervates mucous membrane of larynx above fissure of glottis External branch 外支 which innervates cricothyroid Cervical cardiac branches 颈心支 : descending to terminate in cardiac plexus Recurrent laryngeal nerves 喉返神经 Ascend in tracheo-esophageal groove Enter larynx posterior to cricothyroid joint, the nerve is now called inferior laryngeal nerve Innervations: laryngeal mucosa below fissure of glottis , all laryngeal laryngeal muscles except cricothyroid

Accessory n. (Ⅺ ) 副神经 Deep to posterior belly of digastric Supplies sternoclidomastoid and trapezius muscle Hypoglossal n.(Ⅻ) 舌下神经 Descends between internal carotid a. and internal jugular v., hooks around external carotid a., to lie on the hyoglossus before entering tongue Supplies muscles of tongue

Cervical part of sympathetic trunk 颈交感干 Formed by superior , middle and inferior cervical ganglia and interganglionic branches Superior cervical ganglion: largest, situated in front of transverse processes of C1~C3 vertebra Middle cervical ganglion: smallest, is at level of transverse processes of C6 vertebra Inferior cervical ganglion: situated at level of C7 vertebra, and may be fused with first thoracic ganglion to form cervicothoracic ganglion 颈胸神经节

Regional anatomy of neck 山东大学医学院 解剖教研室 李振华

Parts and regions of the neck Boundaries Superior－inferior border of mandible, angle of mandible, tip of mastoid process, superior nuchal line, external occipital protuberance Inferior－jugular notch, sternoclavicular joint, superior border of clavicle, acromion, spinous processes of C7

Landmarks Hyoid bone Thyroid cartilage Cricoid cartilage Catotid tubercle Sternocleidomastoid Suprasternal fossa Greater supraclaviclar fossa

Regions Neck 颈 Nape 项部 Anterior region of neck Lateral region of neck Sternocleidomastoid region Nape 项部

Anterior region of neck Suprahyoid region 舌骨上区 Submental triangle 颏下三角 Submandibular triangle 下颌下三角 Infrahyoid region 舌骨下区 Carotid triangle 颈动脉三角 Muscular triangle 肌三角

Lateral region of neck Occipital triangle 枕三角 supraclavicular triangle 锁骨上三角 (greatsupraclavicular fossa) 锁骨上大窝

Skin The natural line of cleavage of the skin are constant and run almost horizontally around the neck

Consists of fat and connective tissue Contents Superficial fascia Consists of fat and connective tissue Contents Platysma Superficial veins Anterior jugular v. External jugular v. Cutaneous nerves Lesser occipital n. Greet auricular n. Transverse nerve of neck Supraclavicular n. Cervical branch of facial n.

Cervical fascia 颈筋膜－three layers Superficial layer (investing fascia 封套筋膜) Encloses trapezius, sternocleidomastoid, posterior belly of digastric and parotid and submandibular glands Attached to bony landmarks of upper and lower boundaries of neck and zygomatic arch of face

Prevertebral layer 气管前层 Encloses viscera of neck: pharynx, larynx, trachea, esophagus, thyroid gland and parathyroid glands Completely surrounds thyroid gland, forming a sheet for it, and bind the gland to larynx Extends from hyoid bone to fibrous pericardium of superior mediastinum

Prevertebral layer 椎前层 Lies anterior to bodies of cervical vertebrae and prevertebral muscles; extends from base of skull downward into the superior mediastinum, continuous with anterior longitudinal lig. and endothoracic fascia Covers subclavian vessels and roots of brachial plexus Extends into upper limb as axillary sheath

Carotid sheath 颈动脉鞘 Formed by components of all three layers of deep cervical fascia Contains common and internal carotid arteries, internal jugular vein, and vagus nerve Ansa cervicalis located on its anterior surface

Suprasternal space 胸骨上间隙 Over the lower part of the anterior triangle, the inversting fascia splits into two layers, which are attached to the anterior and posterior margins of the upper border of the manubrium, between these two layers is a slitlike space, called the suprasternal space Contains connective tissue, and sometimes a lymph node

Pretracheal space 气管前间隙 Lies between pretracheal layer and cervical part of trachea Contains arteria thyroidea ima, inferior thyroid v., unpaired thyroid venous plexus, brachiocephalic trunk and left brachiocephalic v.

Retropharyngeal space 咽后间隙 Lies between prevertebral layer and buccopharyngeal fascia Prevertebral space 椎前间隙 Lies between prevertebral muscles, cervical part of vertebral column and prevertebral layer

Suprahyoid region Submental triangle 颏下三角 Lies below the chin and is bounded laterally by anterior bellies of digastric, and inferiorly by the body of hyoid bone Covered by skin, superficial fascia and investing fascia Floor－mylohyoid muscles Contents－submental lymph nodes

Submandibular triangle 下颌下三角 Bounded by anterior and posterior bellies of digastric and lower border of the body of the mandible Covered by skin, superficial fascia, platysma and investing fascia Floor－ mylohyoid, hyoglossus and middle constrictor of pharynx Contents－submandibular gland, facial a., v., hypoglossal n. and v., lingual n., submandibular ganglion and submandibular lymph nodes

Infrahyoid region Carotid triangle 颈动脉三角 Bounded by anterior border of sternocleidomastoid, superior belly of omohyoid and posterior belly of digastic muscles Covered by skin, superficial fascia, platysma and investing fascia Floor－prevertebral fascia and lateral wall of pharynx Contents－common carotid a. and its branches, internal jugular v. and its tributaries, hypoglossal n. with its descending branches, the accessory and vagus nerves, and part of the chain of deep cervical lymph nodes

Posterior belly of digastic muscle Superficial－great auricular n., retromandibular v., cervical branch of facial n. Deep－internal and external carotid a., internal jugular v., Ⅹ～Ⅻ cranial n. and cervical part of sympathetic trunk Superior－posterior auricular a., facial a. and glossopharyngeal n. Infeior－occipital a. and hypoglossal n.

Muscular triangle 肌三角 Bounded by midline of the neck, superior belly of the omohyoid and anterior border of the sternocleidomastoid. Covered by skin, superficial fascia, platysma, anterior jugular v., coutaneous n. and investing fascia Floor－prevertebral fascia Contents－sternohyoid, superior belly of omohyoid, sternothyroid, thyrohyoid, thyroid gland, parathyroid gland, cervical part of trachea and esophagus

Thyroid gland 甲状腺 Shape and position Fibrous capsule: H-shape Left and right lobes: lie on either side of inferior part of larynx and superior part of trachea, extend from middle of thyroid cartilage to level of sixth trachea cartilage Isthmus: overlies 2nd to 4th tracheal cartilage Pyramidal lobe: some times arises from isthmus Fibrous capsule: A sheath of pretracheal fascia which is attached to arch of cricoid and thyroid cartilages, hence, the thyroid gland moves with larynx during swallowing and oscillates during speaking

Relations Anteriorlly－skin , superficial fascia, investing fascia, infrahyoid muscles and pretracheal layer Posteromedialy－ larynx and trachea, pharynx and esophagus, recurrent laryngeal n. Posterolateraly－carotid sheath and cervical part of sympathetic trunk

Arteries of thyroid gland and nerves of larynx Superior thyroid a. Branch of external carotid a. Runs superficial and parallel to the external branch of superior laryngeal n. to reach the upper pole of thyroid gland Gives off superior laryngeal a. in company with internal branch of superior laryngeal n.

Superior laryngeal nerve Internal branch which pierces thyrohyoid membrane to innervates mucous membrane of larynx above fissure of glottis External branch is fine n., which descends in company with the superior thyroid a. and supplies cricothyroid

Inferior thyroid artery 甲状腺下动脉 Branch of thyrocervical trunk off subclavian a. Turns medially and downward, reaches the posterior border of the thyroid gland and is closely related to the recurrent laryngeal n. Supplies inferior pole of thyroid gland Recurrent laryngeal nerves 喉返神经 Ascend in tracheo-esophageal groove Pass deep to the lobe of the thyroid gland and come into close relationship with the inferior thyroid a. Cross either in front of or behind the artery of may pass between its branches Nerves enter larynx posterior to cricothyroid joint, the nerve is now called inferior laryngeal nerve Innervations: laryngeal mucosa below fissure of glottis , all laryngeal laryngeal muscles except cricothyroid

Arteria thyroid ima 甲状腺最下动脉 May arise (4%) from the brachiocephalic a. or aortic arch Venous drainage Superior and middle thyroid veins into internal jugular vein Inferior thyroid veins to left brachiocephalic vein

Parathyroid gland 甲状旁腺 Yellowish-brown, ovoid bodies Position Two superior parathyroid glands: lie at junction of superior and middle third of posterior border of thyroid gland Two inferior parathyroid glands: lie near the inferior thyroid artery, close to the inferior poles of thyroid gland Function: regulate calcium and phosphate balance and is therefore essential for life

Cervical part of trachea 气管颈部 Begins at lower end of larynx－level of C6 vertebra Consists of a series of incomplete cartilage rings Extends into thorax Relations in the neck Anteriorly The skin , superficial fascia, investing fascia, suprasternal space and jugular arch, infrahyoid muscles and pretracheal fascia, isthmus of thyroid gland ( in front of the 2nd to 4th tracheal cartilage), inferior thyroid v. and unpaired thyroid venous plexus, arteria thyroid ima ( if present), and left brachiocephalic v. in child

Laterally The lobes of the thyroid gland ( down as far as the sixth ring) and the carotid sheath Posteriorly The right and left recurrent laryngeal nerves, the esophagus

Cervical part of esophagus 食管颈部 Connecting the pharynx at level of C6 vertebra Consists of smooth muscle tube Relations of the neck Anteriorly Trachea , recurrent laryngeal nerves ascend, one on each side, in the groove between the trachea and esophagus Posteriorly Prevertebral layer of cervicl fascia, longus colli, and vertebral column Laterally Lobe of the thyroid gland and carotid sheath

Sternocleidomastoid region 胸锁乳突肌区 Covered by sternocleidomastoid Contents Ansa cervicalis Carotid sheath Cervical plexus Cervical part of synpathetic trunk

Root of neck 颈根部 Formed at thoracic inlet by Anteriorly－manubrium sterni Posteriorly－body of first thoracic vertebra Laterally－first rib and costal cartilage

Contents Cupula of pleura－extends up into the neck, over the apex of lung, 2～3cm above the medial third of clavicle Subclavian v. Subclavian a. Thoracic duct Right lymphatic duct Vagus n. Phrenic n.

Lateral region of neck 颈外侧区 Bounded by posterior border of sternocleidomastoid, anterior border of trapezius and middle third of clavicle Divided by inferior belly of omohyoid into occipital and supraclavicular triangles

Triangle of the vertebral a. 椎动脉三角 Boundaries Medially－longus colli Laterally－scalenus anterior Inferiorly－first part of subclavian a. Apex－transvese procss of C6 Posteriorly－cupula of pleura, transvese procss of C7, anterior rami of C8 spinal nerves, costal neck of 1st rib Anteriorly－carotid sheath, phrenic n. and arch of thoracic duct (left) Contents Vertebral a. Inferior thyroid a. Cervical part of sympathetic trunk Cevicothoracic ganglion

Occipital triangle 枕三角 Bounded by posterior border of sternocleidomastoid, anterior border of trapezius and superior border of inferior belly of omohyoid Covered by skin, superficial fascia, and investing fascia Floor－prevertebral fascia and scalenus anterior, scalenus medius, scalenus posterior, splenius capitis and levator scapulae Conents Accessory n.－emerges above the middle of the posterior border of sternocleidomastoid and crosses the occipital triangle to trapezius Cervical and brachial plexuses

Supraclavicular triangle 锁骨上三角 Bounded by posterior border of sternocleidomastoid, inferior belly of omohyoid and middle third of clavicle Covered by skin, superficial fascia, and investing fascia Floor－prevertebral fascia and inferior parts of scalenus Conents Subclavian v. and venous angle Subclavian a. Brachial plexus

Dissection Platysma

Cutaneous nerves and superficial veins Lesser occipital n. External jugular vein Greet auricular n. Transverse nerve of neck Supraclavicular n. Anterior jugular vein

Submendibular gland Digastric Accessory n. Hypoglossal n. Superior thyroid a. Cervical plexus Ansa cervicalis Sternothyroid Phrenic n. Sternohyoid Omohyoid Vagus n.

Hypoglossal n. Vagus n. Internal branch Superior thyroid a. External branch Vertebral a. Inferior thyroid a.

Inferior thyroid a. Vagus n. Recurrent laryngeal n. Thoracic duct

Inferior thyroid a. Vertebral a. Transvers cervical a. Thyrocervical trunk Costocervical trunk Suprascapular a. Internal thoratic a.