SURGICAL ANATOMY OF

NECK
DEVELOPMENT
• Structures in the neck that are
innervated by the cranial nerves
are derived from the branchial
apparatus.
SURFACE ANATOMY

MANDIBLE

MASTOID
• MANDIBLE- superficial lobe of the submandibular gland is
palpable inferior to the lower border of the body of the
mandible, just anterior to the angle. The tail of the
parotid gland is palpable just posterior to the angle of the
mandible.
• tip of the mastoid is palpable posterior to the lobule,
where the sternocleidomastoid muscle inserts
• HYOID- important bony landmark IN NECK. superior to
the thyroid cartilage, the hyoid is a horseshoe-shaped
bone with a central body and paired greater and lesser
cornus
• The greater cornu acts as a guide to the lowermost
extent of the marginal mandibular branch of the facial
nerve and the level of the hyoid divides nodal levels II
and III.
• Thyroid- lobes deep to SCM
ROOT OF THE NECK

CHASSAIGNAC’S- scalene
 SKIN OF THE NECK
• Relaxed skin tension lines of neck-
perpendicular to the fibres of
platysma
• They create skin creases that run
transversely wen skin is not under
tension
• Incison along- cosmeticaly
acceptable scars
• VASCULAR SUPPLY- branches of facial, postauricular, occipital
and subclavian arteries
• Accompanied with the veins form subdermal plexus –
supplying the overlying skin
• Hence skin flap raised in sub platysmal plane to preserve blood
supply to skin and prevent skin necrosis
• Venous drainage into internal and external jugular veins
LYMPHATICS

PAROTID LYMPH NODES- common site for occult nodes in skin malignancy-
neckdissection+ parotidectomy
FASCIAL LAYERS

• Neck- Superficial and deep

fascial planes
• Deep fascial layer
• the superficial investing
layer
• the visceral / pretracheal
layer
• the deep layer/prevertebral
facsia
SUPERFICIAL CERVICAL FASCIA
• Invests the platysma muscle
• Inferiorly, forms apouneurosis and attaches to the skin of
the neck /become continuos with the fascia of deltoid
and pectoralis major muscles
 INVESTING LAYER

• ANTERIORLY- hyoid,
acromion, clavicle,
sternum
• Arises - ligamentum nuchae INVESTING LAYER
and the spinous process of
the cervical vertebrae
• Superioly- superior nuchal
lines, mastoid tip, zygoma
• Enclose- SCM, trapezius,
splits to enclose parotid and
the deeplayer fuses with
fascia of ICA
• CAROTID SHEATH- medial to
SCM. Enclose- CCA, ICA and
ECA , IJV and vagus
PRETRACHEAL FASCIA
 • Encompasses the posterior
PREVERTEBRAL FASCIAneck muscles, the scalene
muscles and the vertebrae
• forms the floor of the
posterior triangle
• Deep limit of neck dissection
• alar fascia supplementary
layer of fascia
 anterior to the prevertebral
fascia
 extending from the skull base
to the posterior mediastinum
to the level of the T2
 Danger space
 MARGINAL MANDIBULAR NERVE
• ORIGIN- lower division of the
facial nerve after the
stylomastoid foramen
• COURSE-anteriorly and
inferiorly from the lower
aspect of the parotid gland,
extending to the level of the
greater cornu of the hyoid at
its lowest point
• Passes superficial to facial
vessels and across the
mandible to supply depressor
anguli oris, depressor labii
inferioris and mentalis
muscles.
• Incisions -below the level of greater cornu of the hyoid, 2
finger breaths below the lower border of the mandible,
to avoid injury to the nerve.
• at risk- submandibular gland excision and level I lymph
node clearance
• Flap raised in immediate subplastysmal plane, nerve
located, incision inferior to the nerve to retract the nerve
above level of mandible
• Injury-lower facial assymetry
CERVICAL BRANCH OF FACIAL NERVE- lowest branch,
supplies platysma
GLOSSOPHARYNGEAL
• exits the skull  thru anterior compartment of the jugular
foramen
• then passes between the IJV and the ICA
• Descnds anterior to the ICA.
• curves anteriorly around the stylopharyngeus muscle, deep to
hyoglossus
• and pierces the lower fibres of the superior constrictor
tympanic Lesser petrosal Carotid sinus &
carotid body
Pharyngeal-join vagus Motor- styloglossus lingual
and sympathetic trunk
fibres to form
pharyngeal plexus
 VAGUS
• Leaves the skull thru the
middle compartment of the
jugular foramen
• Superior ganglion of the
vagus - just inferior to the
jugular foramen
• Lower in the neck the nerve
dilates to form the inferior
ganglion
• The vagus nerve runs
posterior in carotid sheath,
with the IJV and common
carotid artery
 BRANCHES

1. Auricular
2. Carotid body branches
3. Pharyngeal
4. Superior laryngeal nerve- internal
and external laryngeal nerve at level
of hyoid
• runs with the superior thyroid artery
over the inferior constrictor before
piercing it
• Provide motor supply to the
cricothyroid muscle, the only intrinsic
laryngeal muscle not supplied by the
recurrent laryngeal nerve.
• JOLLS TRAINGLE
5. CARDIAC BRANCH
6. RLN- ductus arteriosus
artery of 6th arch obliterates on
right
• Right- hooks around
subclavian artery
 Passes medially to TEF
• Left- leaves vagus at
lowerpart of neck
 Loop around lig arteriosum,
arch of aorta
 Back to TEF
• RLN and Inferior thyroid
artery- deep to
artery/superficial/b/w
branches
• All intrinsic laryngealmuscles
except cricothyroid
• BEARHS TRIANGLE- laterally
CCA, inferior thyroid and
recurrent laryngeal nerve
• exit the skull via the middle
compartment of the jugular
foramen
SPINAL ACCESSORY
• pass deep to the styloid
process and the posterior
belly of the digastric muscle.
• courses across level II,
before penetrating the
sternocleidomastoid muscle
• leaves the posterior aspect
of the muscle 1 cm above
Erb’s point, where the
cervical plexus branches
emerge
IATROGENIC – LEVEL5
DISSECTION
HYPOGLOSSAL

• motor innervation to all the intrinsic muscles of the tongue

and all extrinsic muscles except palatoglossus, supplied by the
vagus nerve.
• Exits skull thru the hypoglossal canal , runs deep to the IJV and
courses around the vagal ganglion.
• curves around the carotid bifurcation
• passes inferior to the greater horn of the hyoid before coursing
superiorly, superficial to hyoglossus to reach the tongue.
CERVICAL PLEXUS
Arises from the anterior rami of upper 4 cervicalspinal nerves.
Lies deep to prevertebral fascia and passes over scalenus medius muscle
Semsory and motor branches

• Sensory or cutaneous
branches emerge from
posterior border of SCM 1
cm superior to emergence of
the spinal accessory nerve at • Muscular branches
a point termed Erb’s point.
• Branches
Ansa cervicalis Phrenic nerve
Lesser Transvers C3,C4,C5
occipital e cervical Segmental supply Segmental
Greater supraclavi to SCM branches to
auricular cular trapezius
CERVICAL SYMPATHETIC TRUNK

• the superior, middle and inferior cervical ganglia.

• Injury to the cervical sympathetic trunk during head and neck surgery
causing Horner syndrome, characterized by ipsilateral ptosis and meiosis
with anhydrosis
 BRACHIAL PLEXUS

• Nerve plexus that lies

partly in the posterior
triangle of the neck and
partly in the axilla.
• ventral rami of C5, C6, C7,
C8 and T1 spinal nerves
• five stages (roots, trunks,
divisions, cords and
branches)
• Roots – located behind the
scalaneus medius and
anterior muscle
• Trunk also lies in relation to
scaleus anterior muscle
• Lower trunk lies in the
subclavian triangle

• Erbs point
BLOOD VESSELS
Common carotid artery
• Left- arises from the arch of the aorta
• Right- from the brachiocephalic artery, termed the innominate
artery
• travels in the carotid sheath with the IJV and the vagus nerve.
• The cervical sympathetic trunk lies deeper to it
• branches into internal and external branches at the level of the
greater cornu of the hyoid bone.
• At point of bifurcation , dilates to form the carotid sinus contains
baroreceptors
• The carotid body lies deep to the bifurcation and contains
chemoreceptors.
EXTERNAL CAROTID ARTERY
• multiple branches after the bifurcation

When ECA ligated for epistaxis, the ascending pharyngeal branch

is preserved, because of its supply to the skull base and dura
INTERNAL CAROTID ARTERY
• no branches in the neck and lies deep and lateral to the
external branch after the bifurcation
• runs beneath the posterior belly of digastric - enter the
skull thru the carotid canal and supplies intracranial
contents, with the vertebral artery via the circle of Willis
• IJV which runs antero-laterally to the artery and the
pharynx
• superior laryngeal nerve and pharyngeal vessels- medial
to the artery
• The cervical sympathetic trunk and its superior ganglion
lie deep to the internal carotid.
SUBCLAVIAN ARTERY

• Right-arises from the brachiocephalic artery

• Left- arises from the arch of the aorta
• scalenus anterior muscle crosses in front of the artery to
reach the first rib for insertion. The muscle divides the
subclavian artery into three parts.
• 1st part lies deep to sternocleidomastoid and the strap
muscles but may extend above the clavicle so is at risk during
procedures in the supraclavicular fossa.
• Branches- vertebral, thyrocervical, and the internal mammary
arteries.
• Thyrocervical trunk has 3 branches- inferior thyroid,
suprascapular and transverse cervical
• Inferiorthyroid- runs up along the medial margin of scalenus
anterior then turns medially just below the transverse process
of C6 vertebra and finally it descends on the longus colli to
reach the inferior pole of the thyroid gland. The branches -
ascending cervical, inferior laryngeal, pharyngeal, tracheal,
esophageal and glandular to thyroid and parathyroid glands.
• suprascapular artery
turns laterally across
the scalenus anterior
muscle to reach the
posterior triangle

• transverse cervical
artery divides in
superficial and deep
branches in the
posterior triangle
INTERNAL JUGULAR VEIN
• lateral or sigmoid dural venous sinus continues into the
neck as IJV. After exiting the skull via the jugular foramen,
the IJV travels inferiorly in the carotid sheath, anterior
and lateral to the carotids.
• receives tributaries from the inferior petrosal vein, the
common facial vein, the pharyngeal venous system and
the superior and middle thyroid veins.
• relations - jugular vein - the carotid arteries
• the vagus nerve which runs
posteriorly in the carotid sheath
• The sternocleidomastoid muscle - superficial to both the
IJV and the carotid arteries, providing protection from
penetrating trauma.
• The posterior belly of digastric and the inferior belly of the
omohyoid muscle both cross over the IJV.
• Inferiorly the IJV drains into the brachiocephalic veins on
both sides, with only one valve before draining into the
superior vena cava and eventually into the right atrium.
• Because of backflow from the right atrium the IJV has a
pressure wave.
• The thoracic lymphatic duct drains into the posterior
aspect of the IJV, at the intersection with the subclavian
vein in Chassaignac’s triangle
FACIAL VEINS
• The venous drainage of the face
and oral cavity -facial and
lingual veins that form a venous
plexus in the submandibular
triangle.
• drains into the jugular vein that
drains into the common facial
vein
• common facial vein also
receives drainage from the
retromandibular vein which
passes through the parotid
gland
• IJV