CLINICAL ANATOMY OF THE NECK. OPERATIVE SURGERY OF REGIONS AND ORGANS OF THE NECK Lecture # 2 Plan of Lecture 1. Neck: Regions and triangles 2. Fasciae, interfacial cellulous spaces of the Neck 3. Vessels, nerves and lymphatic system of the Neck 4. Operative surgery of the Neck 1 2 Superior border of the Neck  ledge of the chin (protuberantio mentalis),  foundation of the jaw (basis mandibulae) and its branch (ramus mandibulae),  external acoustic duct,  mastoid process,  linea nuchea superior,  external occipital ledge (protuberantia oссipilalis externa) or the most prominent point of this ledge - the Inion. 3 Inferior border of the Neck  jugular notch of the sternal bone  superior border of clavicle  acromial process of the scapula  imaginary line between the acromion and spinal process of the 7th cervical vertebra Cartilages of the Neck 4 5 Regions of the Neck Division: - anterior; - posterior. Border between: - Imaginary line drawn between the apex of the mastoid process and acromion, or - Frontal plane passing through the transverse process of the cervical department of the vertebral column, or - Lateral margins of the trapezoid muscle. This division has also anatomic base: deep fascia of the neck is fasten to transversal processes. Passing through the hyoid bone horizontal line subdivides the Neck into the suprahyoid (A) and infrahyoid (Б) regions. 6 MEDIAL (anterior) TRIANGLE OF THE NECK Boundaries o Superior - Inferior border of the mandible o Lateral - Anterior border of the sternocleido- mastoid m. o Medial - Midline of the neck 7 Medial triangle Lateral triangle http://anatomy.uams.edu/htmlpages/anatomyhtml/ Medial Triangle: Boundaries  Subdivisions: - Suprahyoid region o Submandibular (digastric) triangle o Submental triangle o Lingual (Pyrohov) triangle - Infrahyoid region o Carotid triangle o Omotracheal (muscular) triangle 8 The Submental Triangle  Located between the two anterior bellies of digastric muscles. Posterior and inferior: limited by hyoid bone.  Structures – submental lymph nodes - drain the floor of the mouth. – mylohyoid muscle arise from the body of the hyoid bone and insert into the mylohyoid line of the inside of the mandible. 9 Submandibular triangle: Boundaries  Also known as digastric triangle  Superiorly(base) – base of mandibla  Anteroinferiorly – anterior belly of digastric m.  Posteroinferiorly – posterior belly of digastric m. & stylohyoid m. 10 Submandibular triangle  contents of the submandibular triangle are structures passing through: – facial artery – lingual nerve and submandibular ganglion – submandibular duct – lingual artery – hypoglossal nerve (XII)  the lingual nerve and submandibular duct pass through a gap between the hypoglossal and mylohyoid muscles  the lingual artery passes deep to the hyoglossus muscle. 11 12 Lingual triangle N. hypoglossus Fibrous loop for intermediate digastric tendon Mylohyoid muscle 13 Ligation of the lingual artery Access line to lingual artery Carotid triangle  Trigonum caroticum or trigonum Beclare  Borders: - Medial: Superior belly of the omohyoid m. - Lateral: Medial margin of the SCM - Superior: Posterior belly of the digastric m. 14 Deep dissection in carotid triangle 15 16 Nerves within the Carotid Triangle 17 Denudation and ligation of the common carotid artery Access line to common carotid artery Topography of neurovasal bundle 18 Denudation and ligation of the external carotid artery Access line to external carotid artery Ligation and cutting of the facial artery Topography of branches of common carotid artery Omotracheal (muscular) triangle 19 Content: thyroid and parathyroid glands, trachea, esophagus and sympathetic nerve trunk. Borders: Superiolateral: Superior belly of the omohyoid muscle Medial: Anterior median line of the Neck Inferior: Anterior border of the SCM 20 21 Lateral Triangle: Boundaries  The lateral (or posterior) triangle is limited by the superior edge of the clavicle, back edge of the sterno- cleidomastoid muscle and trapezoid muscle.  Within the borders of the lateral triangle omotrapezoid, or occipital and omoclavicular, or subclavian, triangles are allocated. 22 Omotrapezoid triangle 23 Omoclavicular triangle 24 Borders: - Medial: Inferior part of SCM - Lateral: Inferior belly of the omohyoid m. - Inferior: Superior margin of clavicle Floor: Scalene muscle a.&v. subclavia Classification of cervical fasciae 1. Superficial fascia. 2. Investing, or Deep, fascia. a. Anterior, or superficial, layer of investing fascia; b. Middle layer of investing fascia, or fascia of infrahyoid muscles, because it is in front and below hyoid bone only; c. Prevertebral layer (posterior, or deep, layer of investing f.); 3. Visceral fascia, or endocervical fascia, (pretracheal and buccopharyngeal layers). 25 Fascies of the Neck 26 27 1. Superficial cervical fascia 28 2a. Superficial layer of Investing, or Deep, Fascia 29 2b. Middle layer of the Investing fascia, or fascia of infrahyoid muscles 2c. Prevertebral layer of Investing, or Deep, Fascia 31 Carotid Sheath 32 3. Visceral Fascia Pretracheal f. Buccofaringeal f. 34 Interfacial spaces Spatium interaponeuroticum suprasternale Spatium previscerale Spatium retroviscerale Spatium prevertebrale Spatium vasonervorum Lateral adipose spaces 35 Scalene muscles 1. Anterior scalene 2. Middle scalene 3. Posterior scalene Actions of scalenes muscles Unilaterally: Laterally flex the head and neck to the same side, rotate head and enck to the opposite side Bilaterally: Elevate the ribs during inhalation, flex the head and neck 1 2 3 Structures of deep neck 36 Inferior jugular bulb and Thoracic Duct (Pyrohov`s angle) 37 38 39 External Carotid Artery 40 41 42 43 44 Cervical Lymph Nodes 1. Preauricular 2. Postauricular 3. Occipital 4. Submental 5. Submandibular 6. Jugulodigastric 7. Superficial cervical 8. Posterior cervical 9. Deep cervical chain 10. Supraclavicular 45 Main surgical accesses to organs of the Neck: 1 –oblique; 2 – vertical; 3 – transversal; 4 – combined. 46 Combined incisions Y Incision McFee Incision H Incision J Incision 48 Position of the patient at operations on the neck 49 Zones of Penetrating Trauma Typical localization of phlegmons and abscesses of the Neck 50 Sagittal section: 1 – retropharingeal abscess; 2 – epidural abscess; 3 – nuchean region phlegmon; 4 – retrotracheal abscess; 5 – presternal abscess; 6 – intraaponeurotic suprasternal abscess; 7 – abscess in the previsceral space; 8 – retroesophagal abscess Horizontal section: 1 – phlegmon around SCM muscle; 2 – abscess in the previsceral space; 3 – retroesophagal abscess; 4 – deep posterior phlegmon of neck; 5 – infratrapezoid phlegmin; 6 – cervical neurovasal bundje phlegmon Typical accesses to the opening of abscesses and phlegmon of the neck 1 - submental abscess, 2 - submandibular abscess, 3 - peripharyngeal abscess, 4, 5 –phlegmon of vascular sheath 6 - Kyutner’s section, 7 - Kerven’s section, 8 - phlegmon of the lateral neck triangle, 9 - pretracheal abscess and purulent strumitis, 10 - suprasternal interapouneurotical abscess. 52 Drainage scheme of cervical phlegmons and abscesses 1 – submandibular phlegmon; 2 – neurovasal bundle phlegmon; 3 – pretracheal phlegmon; 4 – anterior mediastinum abscess; 5 – abscess around SCM muscle; 6 – phlegmon of lateral triangle 53 Infraclavicular Approach to the Subclavian Vein 54 Infraclavicular catheterization of subclavian vein Points of needle insertion: 1 – by Jillies; 2 – by Obanjak; 3 – by Willson Direction of the needle during punction VISHNEVSKY’S VAGOSYMPATHETIC NOVOCAIN BLOCKADE 1 – sternocleidomastoid muscle 2 – prevertebral sheet of cervical fascia 3 –common carotid artery, internal jugular vein 4 – visceral sheet of endocervical fascia 5 – sympatic trunk 6 – n. vagus 7 – main cervical neurovasal bundle 8 – retrovisceral interfascial cervical space (place for Novocaine injection) 56 Incisions of the high breathe ways 1 – thyreotomy; 2 – conicotomy; 3 – cricotomy; 4 – superior tracheotomy; 5 – inferior tracheotomy 57 LARYNGOTOMY 58 LARYNGOTOMY INSTRUMENTS: •Scalpel •Tube for tracheostomy •Syringe 10 ml •Suture material •Fix rope •Thermovent 59 60 Conicothyroid membrane 61 Conicothyroid membrane Posterior wall of trachea 62 Posterior wall of trachea 63 Posterior wall of trachea 64 Tracheostomy Tracheostomy: position Tracheostomy Tracheostomy Tracheostomy Tracheostomy Tracheostomy 72 Thyroidectomy: position and approach 73 Thyroidectomy 74 Thyroidectomy 75 Thyroidectomy 76 Subtotal Thyroidectomy Thank you for attention!