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Home , Ansa cervicalis, Buccopharyngeal fascia, Carotid sheath, Cervical fascia, Deep cervical fascia, Occipital triangle

2019.Spring of the

Lecture Lab 2/19(二) PM 1-6 Posterior triangle , 2 Hours + 2 Hours 2/26(二) PM 1-6 Anterior triangle, 1.5 Hours + 3.5 Hours 3/ 5(二) AM 8-12 Deep structure of the neck, 1 Hour + 3 Hours 3/12(二)AM 8-12 Face and scalp, 2 Hours + 2 Hours 3/19(二) PM 1-6 Lect. + Face and scalp lab. 2 Hours

參考書: Anatomy of the Head and Neck, by George H. Paff 電子資源: Grant's Dissection Videos /Acland’s video atlas of human anatomy

賴逸儒 [email protected] Outline

The Neck: neurovascular structure/ viscera The • Posterior triangle • Anterior triangle and spaces of the neck Triangles of the neck - Sternocleidomastoid muscle (胸鎖乳突肌) - Posterior triangle / anterior triangle

1= SCM 5= 2= 6= Digastric, AB 3= 7= Digastric ,PB 4= Omohyoid, PB 8= Hyoid 9= Omohyoid, AB The fascia of the neck • Superficial fascia- between skin and deep fascia • Deep fascia Superficial (continuous, loose subcutaneous tissue)

 Skin  Deep fascia (investing layer)  , vessels, lymph- supply skin  Fatty (except: eyelid)  Scalp <-- --> , upper extremity  Platysma: through the superficial Deep fascia: fascia •Investing Platysma (頸闊肌)

• Broad, thin muscle  Deltoid and pectoris major (skin, Inferior)  Mandible, lower face  Depressor muscles of mouth • Shaving, grimace • branch of facial (CN. VII) (muscular fascia) • Investing

• Pretracheal I.F Tr • Prevertebral

• • # posterior Investing Layer of Deep Cervical Fascia

• Superficial

• Split: Tr - SCM and Trapezius

- Manubrium (Suprasternal space)

# •Continue posteriorly -Periosteum of spinous process, C7 - (#)

Suprasternal space jugular arch Pretracheal layers Deep Cervical Fascia

Muscular portion

Visceral Th Tr portion

carotid sheath V

limited to anterior part of neck; Thin • Superiorly: • Inferiorly: blends with fibrous pericardium • Posteriorly: buccopharyngeal fascia • Laterally: blends with carotid sheath Prevertebral layer • Tubular sheath for and muscles • Cervical sympathetic trunks

Roof/Floor of posterior triangle Prevertebral fascia

Superiorly: cranial base Inferiorly: • blends w/ endothoracic fascia • fuses w/ ant. longitudinal lig.

Prevertebral (Scalene) fascia

Laterally: extends as axillary sheaths

10 Carotid sheath from cranial base to root of neck • Common and internal carotid • Internal • • Carotid sinus nerve • Sympathetic nerve fibers (periarterial plexus)

 Carotid sheath and pretracheal fascia communicate freely with the inferiorly Retropharyngeal space * base --- superior mediastinum (movement of , during swallowing)

Buccopharyngeal fascia

alar fascia (post. lamina of pretracheal fascia; cranium to C7)

Prevertebral fascia * * Clinical box: Fascia planes and the spread of infection

Buccopharyngeal fascia

Prevertebral fascia Infra-hyoid muscle

Investing layer of deep fascia Esophagus Supra-sternal space

Pretracheal layer of deep fascia pericardium Sternocleidomastoid muscle (SCM) Posterior cervical triangle/Anterior cervical triangle

•Mastoid process •Superior nuchal line

•Lesser supraclavicular

Action of SCM • Unilateral contraction • Bilateral contraction: chin lift

Sternal head Motor: CN XI, spinal Clavicular head Action of SCM

Unilateral contraction: -lateral flexion with rotation - tilts head to same side Trapezius (斜方肌) 1. Muscle of the back 2. Act on pectoral girdle 3. Produce movement of cranium 4. Motor: CN XI, spinal accessory nerve

Trapezius test • Shrug the Trapezius

Splenius Posterior triangle (= + omoclavicular triangle) Boundary -SCM, Trapezius, mid-clavicle

Roof: SC

PS LS Floor MS AS •Splenius capitis (SC) PS •Levator scapulae (LS) MS AS •Posterior scalene •Middle scalene •Anterior scalene Posterior triangle Content of the posterior triangle - cutaneous nerves of the neck

•Branches of : anterior rami, C2,3,4 •Nerve point of neck: midpoint of posterior border of the SCM •Skin of the neck, sup.-lat. thoracic wall, scalp (auricle- occipital protuberance)

Greater auricular (C2,C3) -parotid sheath -auricle

Transverse cervical (C2, C3): ant. triangle of neck Content of the posterior triangle -

Course: • deep to platysma

Post. auricular v. Retromandibular v. • Cross the SCM • Parallels greater auricular n. • Ant. jugular v. Pierce investing layer Tribute from scalp and neck: Ext. jugular v. • posterior auricular v., retromandibular v. • Transverse cervical v., suprascapular v. Drain into: 1. at apex 2. Spinal accessory nerve(CN XI) Occipital triangle 3. Cutaneous nerves of cervical plexus

Occipital a.

Spinal accessory n.

Spinal accessory n. Subclavian triangle (Omoclavicular triangle;) • Boundary: - SCM, Omohyhoid (posterior belly), Clavicle Omohyhoid • Content: -Anterior belly - Ext. jugular vein (inferior part) - Intermediate - (3rd part; deep)

-Posterior belly - (supraclavicular part) rd Transverse cervical a. -Subclavian artery (3 part) -thyrocervical trunk (lateral branches)

Remark: branches of subclavian artery B * 2 1 3 Thyrocervical trunk

Common carotid a.

Transverse cervical a.

Suprascapular a. Anterior scalene muscle

• 3rd-6th transverse processes Middle st Posterior • 1 rib, scalene tubercle • Lift 1st rib in respiration • Landmark: 1. Subclavian artery, 3 segments 2. , on it 3. Brachial plexus: between Anterior ant.-middle scalene ms. Veins in Posterior cervical triangle 1. External jugular vein -Angle of mandible  subclavian vein -Retromandibular vein + posterior auricular vein - across SCM and enter the triangle - Parallels the greater auricular nerve - drain most scalp and side of face

2.Subclavian vein -Join Int. jugular vein brachiocephalic vein -Main draining of the upper limb Subclavian vein Passes anterior to anterior scalene muscle and phrenic nerve; join with IJV Central Venous Catheterization Anatomical consideration Subclavian vein

Internal jugular vein Nerves associated with the Posterior triangle 1. CN XI: spinal accessory nerve 2. Brachial plexus (spinal nerves, C5-T1) 3. Cervical plexus

Spinal accessory nerve (CN XI, motor) - Superior - middle third SCM - Run on levator scapulae - Deep to Trapezius

- Supply SCM and Trapezius Trunk of XI Injury of spinal accessory nerve The cervical and Brachial plexi

Each divides into an anterior and posterior ramus. The anterior rami of C1 to C8, and T1 form 2 plexi in the neck.

anterior ramus

2.Root of brachial plexus (C5-T1) - Between anterior and middle scalene Phrenic nerve - Cervicoaxillary canal (1st rib, clavicle, sup. border of scapula)  axilla

2

3. Roots of cervical plexus Cervical nerves • C1-C4 spinal nerves: supply the neck region • Anterior ramus (C1-4): cervical plexus • Posterior ramus (C1-3): posterior neck and scalp

Suboccipital n. (C1)

Greater occipital n. (C2) Cervical plexus Anterior rami of , C1,2,3 and most C4, spinal nerve • Series of nerve loops , branches from the loops • Ascending and descending branches (except C1 )

1. Branches to the skin 2. Nerve to diaphragm (phrenic nerve) 3. Nerves to strap muscles of anterior triangle 4. Nerves to muscles of floors at posterior triangle Cervical plexus: branches to the skin • Appear at nerve point • GA (C2,3): ear lobe • LO (C2): parallel SCM • TC(C2,3): anterior triangle • (C3,4) : medial, intermediate and lateral

Lesser occipital n.

Greater auricular n.

Transverse cervical n.

Supraclavicular n. Great auricular n. Nerve to diaphragm : Phrenic nerve •Chiefly C4 (C3~C5) •Motor, sensory, and sympathetic •Lies on: anterior scalene muscle •Descend obliquely with Phrenic n.

C3 spinal nerve

Anterior scalene muscle C5 spinal nerve Phrenic nerve Nerves to strap muscles of anterior triangle: (hypoglossi) Superior root -C1 and C2 -Briefly join (CN XII) -Pass superficial to the

Sup.root

Inf.root

Inferior root gh: branch to geniohyoid -C2 and C3 th: branch to thyrohyoid St: sternothyroid Sh: sternohyoid Oh: omohyoid Ansa cervicalis : Supply 3 of 4

Hypoglossal nerve -Receives C1 fiber -Independently descend from hypoglossal nerve

Thyrohyoid muscle

Sternohyoid muscle Sternothyoid muscle

40 Motor innervation of the anterolateral neck

Superior root of Geniohyoid* Inferior root of Thyrohyoid*

Gilroy, Atlas of Anatomy Inferior root Take home message

• Muscles boundary of neck region • Vessels and nerves of superficial neck regions