Practicle lesson N10

1. Submental triangle
2. Submandibular triangle
3. Carotid triangle
  Submental triangle
The submental triangle (trigonum submentale), which
is also known as the suprahyoid triangle, is part of the anterior
(medial) triangle of the neck. The submental triangle is an unpaired
triangle located between the hyoid bone and the mandible and medial
to the anterior bellies of the digastric muscles.
The borders of the submental triangle:
1.Lateral (away from the midline), formed by the right and left
anterior bellies of the digastric muscles.
2.Inferior (below), formed by the body of the hyoid bone.
The apex of the submental triangle is at the mandibular
symphysis, the site of union of the halves of the mandible during the
early years of life. The hyoid bone forms the base of the triangle,
while the roof is formed by the two mylohyoid muscles, which meet
in a median fibrous raphe. The submental triangle contains important
structures helping in the diagnosis process; for instance, the size of
the submental lymph nodes can serve as a good indicator to
determine whether the metastasis is present or not.
Layers:
1. The skin is thin, mobile, with well-developed subcutaneous tissue. In men, the skin is covered with hair.
2. At the top of the triangle the bundles of right and left m. platysma are layered on top of each other. Closer to the hyoid bone, the submental
triangle is free of m. platysma and is covered by a superficial fascia — the first fascia, by Shevkunenko.
3. The anterior bellies of m. digastricus are enclosed in capsules, formed by the second fascia of the neck. In loose connective tissue between
the second fascia and m. mylohyoideus (sometimes on top of the second fascia) are located 1 - 2 submental lymph nodes, nodi lymphatici
submentales. They drain the lymph from the tip of the tongue, the middle part of the bottom of the oral cavity and the middle part of the lower
lip.
In the midline of the neck bunches m. mylohyoideus form a suture, raphe, in the form of a thin connective tissue strip.
  Submental triangle
3. Under m. mylohyoideus is a rounded m. geniohyoideus, and
deeper them - fan-shaped m. genioglossus, directed from the
mental spine to the root of the tongue.
Rear and outside of this muscle is located m.
hyoglossus, on which are located sublingual salivary gland and n.
lingualis, which pass to the tongue through the gap between m.
genioglossus and m. hyoglossus. From the bottom of the oral
cavity m. Genioglossus and the sublingual salivary gland are
covered with a mucous membrane, separated from them by a layer
of loose connective tissue.
The submental artery is the largest artery of the
cervical branches of the facial artery. This artery emerges just after
the facial artery exits from the submandibular gland. The
submental artery with the same name vein passes from the
submandibular to the submental triangle by the gap between
anterior belly of digastricus and m. mylohyoideus, located closer
to the lower jaw. Here next to the vessels is n. mylohyoideus. It
runs beneath the submental artery and the submental vein. This
nerve is a branch of n. alveolaris inferior, and it's originated before
the latter enters to the foramen mandibulare.
 Trigonum submandibulare
Borders: Superior border is the inferior margin of the mandible.
Anterior and posterior borders are anterior and posterior bellies of
m.digastricus.
Layers:
1. The skin is thin, movable.
2. The subcutaneous fat well developed and sometimes formed the
second chin in fat persons. Nerve supply of the skin is from r.colli n. a
facialis and r.superior n.transversus colli, which are joined here forming
arcus cervicalis superficialis. R.marginalis mandibulae (n.facialis) is
also situated in subcutaneous fat above this arch.
3. The superficial fascia forms the vagina for m.platysma. Platysma
covers the most surface of this triangle except superiolateral angle.
4. The second fascia with its two layers forms a saccus caecus
hyomandibularis (a) for submandibular gland covering it anteriorly and
posteriorly as well. It communicates with the oral cavity by the
submandibular duct. The septas inside of the gland are absent and it can
be separates from the gland easily. Facial vein (b) lies superficially and b
facial artery (c) underlies the gland. At the posterior border of the
triangle v.facialis joins the retromandibular vein and form the common
facial vein. Facial artery turns to the upper deep surface of the gland and c
passes onto the lateral surface of the face. At the inferior border of the
mandible it gives off the submental artery which runs to submental
triangle with corresponding vein and the mylohyoid nerve (the branch of
n.alveolaris inferior).
 Trigonum submandibulare
c
d

5. The muscular layer is presented by two layer:

The Pirogov’s
triangle (1) is described in the
submandibular triangle and is
1
bounded anteriorly by the
posterior margin of the m.
mylohyoideus, posteriorly by
the posterior belly of the
m.digastricus, superiorly by the
n.hypoglossus and the
v.lingualis. The floor is formed
by the m.hyoglossus under
which the a.lingualis is
situated.
 Trigonum caroticum
This triangle (a) bounded by the sternocleidomastoid muscle (SCM)
laterally, posterior belly of digastric muscle superiorly and the superior belly of
omohyoid muscle inferiorly.
1.The skin is thin, movable with superficial fascia and platyzma, with
which it fuses.
Platyzma covers this triangle completely. Under the platyzma and on the II
fascia r.colli n.facialis, r.superior n.transversus colli and v.jugularis anterior are a
situated in the fat.
1.II fascia by Shevkunenko is represented in one layer.
3. Under this fascia the neurovascular bundle of the medial triangle of the
neck is situated. Internal jugular vein, the carotid arteries with it’s branches, the
vagus nerve with it’s n.laryngeus superior (the last one gives off n. thyroideus
superior) are situated covered by lamina parietalis f.endocervicalis, IV fascia
(vagina carotica, PNA). This fascial sheath encloses the neurovascular bundle,
deep lymph nodes, which accompany the internal jugular vein and fat. Carotid
artery lies medially, internal jugular vein lies laterally, n.vagus is between them
and posteriorly. Carotid common artery is projected by bisector of the angle
between the SCM and m.omohyoideus.
The common carotid artery is divided at the level of the upper border of the thyroid cartilage or greater horn of hyoid bone into internal
and external branches. Usually external carotid artery is situated superficially and medially to internal.
 Trigonum caroticum
The internal carotid artery has no branches on the neck in this
triangle.
The external carotid artery gives off 7 branches in carotid
triangle.
1.The superior thyroid artery, which gives off superior laryngeal
artery.
2.The lingual artery.
3.The facial artery, which arises above the lingual one and gives
off ascending palatine artery, which supplies the palatine tonsil.
4.The occipital artery.
5.The sternocleidomastoid artery.
6.The posterior auricular artery.
7.The ascending pharyngeal artery.
In the carotid triangle hypoglossal nerve gives off the superior
root of ansa cervicalis, which descends lying on the internal and
common carotid arteries and joins the inferior root from cervical
plexus.
As a result a loop is formed called ansa cervicalis which supplies the infrahyoid muscles (sternohyoid, sternothyroid, thyrohyoid
and omohyoid).
The deep cervical lymph nodes are situated around the internal jugular vein and form the jugular lymph trunk. The facial vein
enters the carotid triangle over the posterior belly of digastric muscle.
 Trigonum caroticum
The internal jugular (a) vein descends vertically first with the internal
then with the common carotid artery. In front from the common carotid
bifurcation in internal jugular vein drains the common facial vein (b), which
form by connection of:
- v.facialis
- v.thyroidea superior
- v.laryngea superior
- v.lingualis
- r.anterior v.retromandibularis
At the place of common carotid bifurcation is located the sinocarotic
b
reflex zone, which forms vagus, glossopharyngeus nerves and sympatethic
branches. From the zone arises the sinocarotic nerve, which goes to the brain
as component of the glossopharyngeus nerves. The baroreceptors of this zone a
regulate the arterial blood pressure. Behind the common carotid bifurcation is
situated the glomus caroticus, which contain the chemoreceptors. They are
sensitive to the hyperoxygenation and hypercarbodioxygenation of blood.
4. After vagina carotica is coming the V facsia, which is covered the
cervical part of the sympathetic trunk.
The common carotid artery in the neck region is projected by line, which
connects the midpoint of mandibular angle and mastoid process with the
sternoclavicular joint in the right side and with the midpoint of SCM muscle
both legs (cruras) in the left side .