Anantomy of The Neck

THE NECK
Chapters:
1. Areas of the Neck
I. The Anterior Triangle of the Neck
The Anterior Triangle of the Neck

Original Author(s): Oliver Jones
Last updated: May 16, 2023
Revisions: 34
The anterior triangle is a region located at the front of the neck.
In this article, we shall look at the anatomy of the anterior triangle of the neck – its borders, contents and
subdivisions.
Note: it is important to note that all triangles mentioned here are paired; they are located on both the left
and the right sides of the neck.
Borders
The anterior triangle is situated at the front of the neck. It is bounded:
 Superiorly – inferior border of the mandible (jawbone).

 Laterally – anterior border of the sternocleidomastoid.
 Medially – sagittal line down the midline of the neck.
Investing fascia covers the roof of the triangle, while visceral fascia covers the floor. It can be subdivided
further into four triangles – which are detailed later on in this chapter.
By TeachMeSeries Ltd (2023)
Fig 1 – Borders of the anterior triangle of the neck.

Contents
The contents of the anterior triangle include muscles, nerves, arteries, veins and lymph nodes.
The muscles in this part of the neck are divided as to where they lie in relation to the hyoid bone.
The suprahyoid muscles are located superiorly to the hyoid bone, and infrahyoids inferiorly.
There are several important vascular structures within the anterior triangle. The common carotid
artery bifurcates within the triangle into the external and internal carotid branches. The internal jugular
vein can also be found within this area – it is responsible for venous drainage of the head and neck.
Numerous cranial nerves are located in the anterior triangle. Some pass straight through, and others give
rise to branches which innervate some of the other structures within the triangle. The cranial nerves in the
anterior triangle are the facial [VII], glossopharyngeal [IX], vagus [X], accessory [XI], and hypoglossal
[XII] nerves.
Suprahyoid Muscles Infrahyoid Muscles

 Stylohyoid  Omohyoid
 Digastric  Sternohyoid
 Mylohyoid  Thyrohyoid
 Geniohyoid  Sternothyroid
Fig 2 – The extracranial anatomical course of the hypoglossal nerve, through the anterior triangle of the
neck.
Subdivisions
The anterior triangle is subdivided by the hyoid bone, suprahyoid and infrahyoid muscles into four triangles.
Carotid Triangle
The carotid triangle of the neck has the following boundaries:
 Superior – posterior belly of the digastric muscle.

 Lateral – medial border of the sternocleidomastoid muscle.
 Inferior – superior belly of the omohyoid muscle.
The main contents of the carotid triangle are the common carotid artery (which bifurcates within the
carotid triangle into the external and internal carotid arteries), the internal jugular vein, and
the hypoglossal and vagus nerves.
Fig 3 – Carotid triangle of the neck

Clinical Relevance: Medical Uses of the Carotid Triangle
In the carotid triangle, many of the vessels and nerves are relatively superficial, and so can be accessed
by surgery. The carotid arteries, internal jugular vein, vagus and hypoglossal nerves are frequent targets of
this surgical approach.
The carotid triangle also contains the carotid sinus – a dilated portion of the common carotid and internal
carotid arteries. It contains specific sensory cells, called baroreceptors. The baroreceptors detect
stretch as a measure of blood pressure. The glossopharyngeal nerve feeds this information to the brain,
and this is used to regulate blood pressure.
In some people, the baroreceptors are hypersensitive to stretch. In these patients, external pressure on
the carotid sinus can cause slowing of the heart rate and a decrease in blood pressure. The brain
becomes underperfused, and syncope results. In such patients, checking the pulse at the carotid triangle
is not advised.
Submental Triangle
The submental triangle in the neck is situated underneath the chin. It contains the submental lymph
nodes, which filter lymph draining from the floor of the mouth and parts of the tongue.
It is bounded:
 Inferiorly – hyoid bone.

 Medially – midline of the neck.
 Laterally – anterior belly of the digastric
The floor of the submental triangle is formed by the mylohyoid muscle, which runs from the mandible to
the hyoid bone.

Fig 4 – The submental triangle of the neck.
Submandibular Triangle
The submandibular triangle is located underneath the body of the mandible. It contains the submandibular
gland (salivary), and lymph nodes. The facial artery and vein also pass through this area.
The boundaries of the submandibular triangle are:
 Superiorly – body of the mandible.

 Anteriorly – anterior belly of the digastric muscle.
 Posteriorly – posterior belly of the digastric muscle.
Fig 5 – Submandibular triangle of the neck

Muscular Triangle
The muscular triangle is situated more inferiorly than the subdivisions. It is a slightly ‘dubious’ triangle, in
reality having four boundaries. The muscular triangle contains some muscles and organs –
the infrahyoid muscles, the pharynx, and the thyroid, parathyroid glands.
The boundaries of the muscular triangle are:
 Superiorly – hyoid bone.

 Medially – imaginary midline of the neck.
 Supero-laterally – superior belly of the omohyoid muscle.
 Infero-laterally – inferior portion of the sternocleidomastoid muscle.
Fig 6 – Muscular triangle of the neck.
II. The Posterior Triangle of the Neck
The Posterior Triangle of the Neck

Last updated: July 1, 2023
Revisions: 40
The posterior triangle of the neck is an anatomical area located at the posterolateral aspect of the neck.
In this article, we shall look at the anatomy of the posterior triangle of the neck – its borders, contents and
clinical correlations.
Borders
The posterior triangle of the neck has three borders:
 Anterior – posterior border of the sternocleidomastoid.

 Posterior – anterior border of the trapezius muscle.
 Inferior – middle 1/3 of the clavicle.
The roof is formed by the investing layer of fascia, and the floor is formed by the prevertebral fascia
(see fascial layers of the neck).

Fig 1 – The borders and floor of the posterior triangle of the neck.
Contents
Muscles
The posterior triangle of the neck contains many muscles, which make up the borders and the floor of the
area.
A significant muscle in the posterior triangle region is the omohyoid muscle. It is split into two bellies by a
tendon. The inferior belly crosses the posterior triangle, travelling in an supero-medial direction, and
splitting the triangle into two. The muscle then crosses underneath the SCM to enter the anterior triangle of
the neck.
A number of vertebral muscles (covered by prevertebral fascia) form the floor of the posterior triangle:
 Splenius capitis
 Levator scapulae
 Anterior, middle and posterior scalenes
Vasculature
The external jugular vein is one of the major veins of the neck region. Formed by the retromandibular and
posterior auricular veins, it lies superficially, entering the posterior triangle after crossing the
sternocleidomastoid muscle. Within the posterior triangle, the external jugular vein pierces the investing
layer of fascia and empties into the subclavian vein.
The subclavian vein is often used as a point of access to the venous system, via a central catheter.
The transverse cervical and suprascapular veins also lie in the posterior triangle
The subclavian, transverse cervical and suprascapular veins are accompanied by their respective arteries in
the posterior triangle.
The distal part of the subclavian artery can be located as it emerges between the anterior and
middle scalene muscles. As it crosses the first rib, it becomes the axillary artery, which goes onto supply the
upper limb.
Clinical Relevance: The External Jugular Vein
The external jugular vein has a relatively superficial course down the neck, leaving it vulnerable to damage.
If it is severed, in an injury such as a knife slash, its lumen is held open – this is due to the thick layer
of investing fascia (for more information see Fascial Layers of the Neck). Air will be drawn into the vein,
producing cyanosis, and can stop blood flow through the right atrium. This is a medical emergency,
managed by the application of pressure to the wound – stopping the bleeding, and the entry of air.
Nerves
The accessory nerve (CN XI) exits the cranial cavity, descends down the neck, innervates
sternocleidomastoid and enters the posterior triangle. It crosses the posterior triangle in an oblique,
inferoposterior direction, within the investing layer of fascia. It lies relatively superficial in the posterior
triangle, leaving it vulnerable to injury.
The cervical plexus forms within the muscles of the floor of the posterior triangle. A major branch of this
plexus is the phrenic nerve, which arises from the anterior divisions of spinal nerves C3-C5. It descends
down the neck, within the prevertebral fascia, to innervate the diaphragm.
Other branches of the cervical plexus innervate the vertebral muscles, and provide cutaneous innervation to
parts of the neck and scalp.
The trunks of the brachial plexus also cross the floor of the posterior triangle.
Figure 2 – Nerves within the posterior triangle of the neck.

Clinical Relevance: Cervical Plexus Nerve Block
For anaesthesia of the neck area, a cervical plexus block can be used.
Local anaesthetic is injected along the posterior border of sternocleidomastoid at the junction of its
superior and middle thirds. This junction is where the cutaneous branches of the cervical plexus emerge,
known as the nerve point of the neck.
Subdivisions
The omohyoid muscle divides the posterior triangle of the neck into two areas:
 Occipital triangle – located superior to the omohyoid.

 Subclavian triangle – located inferior to the omohyoid. It contains the distal portion of the subclavian
artery
2. Bones of the Neck

I. The Cervical Spine
The Cervical Spine

Original Author(s): Sam Barnes
Last updated: September 8, 2020
Revisions: 57
The cervical spine is the most superior portion of the vertebral column, lying between the cranium and the
thoracic vertebrae.
It consists of seven distinct vertebrae, two of which are given unique names:
 The first cervical vertebrae (C1) is known as the atlas.

 The second cervical vertebrae (C2) is known as the axis.
In this article, we shall look at the anatomy of the cervical vertebrae – their characteristic features,
articulations and clinical relevance.
BodyParts3D, The Database Center for Life Science.
Fig 1 – Overview of the location of the cervical spine.

Characteristic Features
The cervical vertebrae have three main features which distinguish them from other vertebrae:
 Triangular vertebral foramen.
 Bifid spinous process – this is where the spinous process splits into two distally.
 Transverse foramina – holes in the transverse processes. They give passage to the vertebral artery,
vein and sympathetic nerves.
Fig 2 – Characteristic features of a cervical vertebrae

Atlas and Axis
The atlas and axis have additional features that mark them apart from the other cervical vertebrae.
Atlas
The atlas is the first cervical vertebra and articulates with the occiput of the head and the axis (C2).
It differs from the other cervical vertebrae in that it has no vertebral body and no spinous process. Instead,
the atlas has lateral masses which are connected by an anterior and posterior arch. Each lateral mass
contains a superior articular facet (for articulation with occipital condyles), and an inferior articular facet (for
articulation with C2).
The anterior arch contains a facet for articulation with the dens of the axis. This is secured by
the transverse ligament of the atlas – which attaches to the lateral masses. The posterior arch has a
groove for the vertebral artery and C1 spinal nerve.
Axis
The axis (C2) is easily identifiable due to its dens (odontoid process) which extends superiorly from the
anterior portion of the vertebra.
The dens articulates with the anterior arch of the atlas, in doing so creating the medial atlanto-axial joint.
This allows for rotation of the head independently of the torso.
The axis also contains superior articular facets, which articulate with the inferior articular facets of the
atlas to form the two lateral atlanto-axial joints.

Fig 3 – The bony landmarks of the atlas and axis.
Joints
The joints of the cervical spine can be divided into two groups – those that are present throughout the
vertebral column, and those unique to the cervical spine.
Present throughout Vertebral Column
There are two different joints present throughout the vertebral column:
 Between vertebral bodies – adjacent vertebral bodies are joined by intervertebral discs, made of
fibrocartilage. This is a type of cartilaginous joint, known as a symphysis.
 Between vertebral arches – formed by the articulation of superior and inferior articular processes
from adjacent vertebrae. It is a synovial type joint.
Unique to Cervical Spine
There are two joints unique to the cervical spine – the atlanto-axial (x3) and atlanto-occipital joints (x2).
The atlanto-axial joints are formed by the articulation between the atlas and the axis:
 Lateral atlanto-axial joints (x2) – formed by the articulation between the inferior facets of the lateral
masses of C1 and the superior facets of C2. These are plane type synovial joints.
 Medial atlanto-axial joint – formed by the articulation of the dens of C2 with the articular facet of C1.
This is a pivot type synovial joint.
The atlanto-occipital joints consist of an articulation between the spine and the cranium. They occur
between then superior facets of the lateral masses of the atlas and the occipital condyles at the base of the
cranium. These are condyloid type synovial joints, and permit flexion at the head i.e. nodding.
Ligaments
There are six major ligaments to consider in the cervical spine. The majority of these ligaments are present
throughout the entire vertebral column.
Present throughout Vertebral Column
 Anterior and posterior longitudinal ligaments – long ligaments that run the length of the vertebral
column, covering the vertebral bodies and intervertebral discs.
 Ligamentum flavum – connects the laminae of adjacent vertebrae.

 Interspinous ligament – connects the spinous processes of adjacent vertebrae.
Unique to Cervical Spine
 Nuchal ligament – a continuation of the supraspinous ligament. It attaches to the tips of the spinous
processes from C1-C7 and provides the proximal attachment for the rhomboids and trapezius.
 Transverse ligament of the atlas – connects the lateral masses of the atlas, and in doing so anchors
the dens in place.
(Note: Some texts consider the interspinous ligament to be part of the nuchal ligament).
Fig 4 – Ligaments of the cervical spine.

Anatomical Relationships
The cervical spine has a close relationship with several neurovascular structures in the neck.
The transverse foramina of the cervical vertebrae provide a passageway by which the vertebral artery,
vein and sympathetic nerves can pass. The only exception to this is C7 – where the vertebral artery passes
around the vertebra, instead of through the transverse foramen.
The spinal nerves are intimately related to the cervical vertebrae. They extend from above their respective
vertebrae, through the intervertebral foramen created by the joints at the articular processes. Again, C7 is
an exception – it has a set of spinal nerves extending from above (C7) and below (C8) the vertebra.
Therefore, there are eight spinal nerves associated with seven cervical vertebrae.

Fig 5 – The right vertebral artery. Note its course through the transverse foramina of the cervical vertebrae.
Clinical Relevance: Injuries to the Cervical Spine
Jefferson Fracture of the Atlas
A vertical fall onto an extended neck e.g. diving into excessively shallow water can compress the lateral
masses of the atlas between the occipital condyles and the axis. This causes them to be driven apart,
fracturing one or both anterior/posterior arches.
If the fall occurs with enough force, the transverse ligament of the atlas may also be ruptured.
Since the vertebral foramen is large, it is unlikely that there will be damage to the spinal cord at the C1
level. However, there may be damage further down the vertebral column.
Hyperextension (Whiplash) Injury
A rear-end traffic collision or a poorly performed rugby tackle can both result in the head being whipped
back on the shoulders, causing whiplash. In minor cases, the anterior longitudinal ligament of the
spine is damaged which is acutely painful for the patient.
In more severe cases, fractures can occur to any of the cervical vertebrae as they are suddenly
compressed by rapid deceleration. Again, since the vertebral foramen is large there is less chance of
spinal cord involvement.
The worst-case scenario for these injuries is that dislocation or subluxation of the cervical vertebrae occurs.
This often happens at the C2 level, where the body of C2 moves anteriorly with respect to C3. Such an
injury may well lead to spinal cord involvement, and as a consequence quadriplegia or death may occur.
More commonly, subluxation occurs at the C6/C7 level (50% of cases).
Hangman’s Fracture
Hangman’s fracture refers to a fracture of the pars interarticularis (bony column between the superior and
inferior articular facets of the axis). It typically occurs as a result of high velocity hyperextension and
distraction of the head.
Such an injury is likely to be lethal, as either the fracture fragments or the force involved are likely to
rupture the spinal cord; causing deep unconsciousness, respiratory failure and cardiac failure.
Fracture of the Dens
Fractures of the odontoid process represent ~40% of C2 fractures.
Often these fractures are unstable and are at high risk of avascular necrosis – due to the isolation of the
distal fragment from any blood supply. As with any fracture of the vertebral column, there is a risk of spinal
cord involvement.
By James Heilman, MD [CC-BY-SA-3.0], via Wikimedia Commons
Fig 6 – A fracture of the base of the dens.

II. The Hyoid Bone
The Hyoid Bone

Last updated: January 3, 2021
Revisions: 32
The hyoid bone is a ‘U’ shaped structure located in the anterior neck. It lies at the base of the mandible
(approximately C3), where it acts as a site of attachment for the anterior neck muscles.
In this article, we shall look at the anatomical structure, muscular attachments and clinical relevance of the
hyoid bone.
Adapted from work by OpenStax College [CC BY 3.0]
Fig 1 – Position of the hyoid bone in the neck.

Structure
The hyoid is composed of a body, two greater horns and two lesser horns:
 Body – the central part of the bone. It has an anterior convex surface and a concave posterior
surface.
 Greater horn – projects from each end of the body in a posterior, superior and lateral direction. It acts
as a site of attachment for numerous neck muscles.
 Lesser horn – arises from the superior aspect of the hyoid bone, near the origin of the greater horn. It
projects superoposteriorly (toward the styloid process of the temporal bone). The stylohyoid ligament
attaches to the apex of the lesser horn.
Fig 2 – The major parts of the hyoid bone – body, greater horn and lesser horn.
Muscular Attachments
The hyoid bone is unique in the fact that it does not articulate with any other bones, and is suspended in
place by the muscles and ligaments that attach to it.
Indeed, it acts as a site of attachment for many muscles in the neck:
Oral Cavity and Pharynx Suprahyoid Infrahyoid

 Digastric
 Middle pharyngeal constrictor  Thyrohyoid
 Stylohyoid
 Hyoglossus  Omohyoid
 Geniohyoid
 Genioglossus  Sternohyoid
 Mylohyoid
Ligament Attachments
There are three main ligaments that attach to the hyoid bone – stylohyoid, thyrohyoid and hyoepiglottic.
They act to support the position of the hyoid in the neck.
 Stylohyoid ligament – extends from the styloid process of the temporal bone to the lesser horn of the
hyoid bone.
 Thyrohyoid membrane – originates from the superior border of the thyroid cartilage and attaches to
the posterior surface of the hyoid bone and the greater horns.
 Hyoepiglottic ligament – connects the hyoid bone to the anterior aspect of the epiglottis.
Clinical Relevance: Fracture of the Hyoid Bone

The hyoid is well protected by the mandible and cervical spine, so fractures are relatively rare.
Hyoid bones fractures are characteristically associated with strangulation (found in approximately 1/3 of
all homicides by strangulation). It is therefore a significant post-mortem finding.
They can also occur as a result of trauma, with clinical features of pain on speaking, odynophagia and
dyspnoea.
3. Viscera of the Neck

I. The Pharynx
The Pharynx
Original Author(s): Nandhaa Pazhaniappan
Last updated: February 3, 2023
Revisions: 65
The pharynx is a muscular tube that connects the oral and nasal cavity to the larynx and oesophagus.
It begins at the base of the skull and ends at the inferior border of the cricoid cartilage (C6). The pharynx
is comprised of three parts (superior to inferior):
 Nasopharynx
 Oropharynx
 Laryngopharynx.
In this article, we shall look at the anatomy of the pharynx – its structure, neurovascular supply, and any
clinical correlations.
Fig 1 – The three subdivisions of the pharynx and their borders.

Nasopharynx
The nasopharynx is found between the base of the skull and the soft palate. It is continuous with the nasal
cavity and performs a respiratory function by conditioning inspired air and propagating it into the larynx.
This part of the pharynx is lined with respiratory epithelium; ciliated pseudostratified columnar epithelium
with goblet cells.
The posterosuperior nasopharynx contains the adenoid tonsils, which enlarge between 3-8 years of age
and then regress.
Clinical Relevance: Enlarged Adenoid Tonsils
The adenoid tonsils can become pathologically enlarged due to viral infections of the upper respiratory
tract. In the case of recurrent infections, they can become chronically enlarged. When enlarged, the
adenoids can obstruct the opening of the Eustachian tube – which is located close to the adenoid tonsils in
the nasopharynx.
Chronic obstruction of the Eustachian tube prevents the equalising of pressure in the middle ear with the
atmosphere and normal drainage of fluid. This can lead to chronic otitis media with effusion, colloquially
known as glue ear. In this condition, the static fluid and negative pressure in the middle ear provide the
ideal environment for infection.
Oropharynx
The oropharynx is the middle part of the pharynx, located between the soft palate and the superior border
of the epiglottis.
It contains the following structures:
 Posterior one-third of the tongue.

 Lingual tonsils – lymphoid tissue at the base of the tongue.
 Palatine tonsils – lymphoid tissue located in the tonsillar fossa (between the palatoglossal and
palatopharyngeal arches of the oral cavity).
 Superior constrictor muscle
Waldeyer’s ring is the ring of lymphoid tissue in the naso- and oropharynx formed by the paired palatine
tonsils, the adenoid tonsils and lingual tonsil.
The oropharynx is involved in the voluntary and involuntary phases of swallowing.
Fig 2 – Location of the palatine tonsils in the oropharynx

Laryngopharynx
The most distal part of the pharynx, the laryngopharynx is located between the superior border of the
epiglottis and inferior border of the cricoid cartilage (C6). It is continuous inferiorly with the oesophagus.
It is found posterior to the larynx and communicates with it via the laryngeal inlet, lateral to which one can
find the piriform fossae.
The laryngopharynx contains the middle and inferior pharyngeal constrictors.
Clinical Relevance: Pharyngeal Diverticulum (Pouch)
The inferior pharyngeal constrictor is split into two parts; the thyropharyngeus and the cricopharyngeus.
This area between the two is a weak area in the mucosa.
Normally during swallowing, the thyropharyngeus contracts as the cricopharyngeus relaxes, allowing the
bolus of food to be propelled into the oesophagus and preventing the intrapharyngeal pressure from rising.
If this coordinated relaxation of the cricopharyngeus does not occur, the intrapharyngeal pressure tends to
rise and pharyngeal mucosa forms a midline diverticulum in the area between the thyropharyngeus and
cricopharyngeus. It is possible for food to accumulate here, leading to dysphagia.
Fig 3 – Pharyngeal diverticulum.
Muscles
There are two main groups of pharyngeal muscles; longitudinal and circular.
The muscles of the pharynx are mostly innervated by the vagus nerve – the only exception being
the stylopharyngeus (glossopharyngeal nerve).
Circular
There are three circular pharyngeal constrictor muscles – superior, middle, and inferior. They are arranged
like stacked glasses, which form an incomplete muscular circle around the pharynx.
The circular muscles contract sequentially from superior to inferior to constrict the pharyngeal lumen. and
thus propel the bolus of food inferiorly into the oesophagus.
 Superior pharyngeal constrictor – the uppermost pharyngeal constrictor. It is located in the

oropharynx.
o Originates from the pterygomandibular ligament, alveolar process of mandible, medial
pterygoid plate and pterygoid hamulus of the sphenoid bone.
o Inserts posteriorly onto the pharyngeal tubercle of the occiput and the pharyngeal raphe.
 Middle pharyngeal constrictor – located in the laryngopharynx.
o Originates from the stylohyoid ligament and the horns of the hyoid bone.
o Inserts posteriorly into the pharyngeal raphe.
 Inferior pharyngeal constrictor – located in the laryngopharynx. It has two components:
o Thyropharyngeal fibres originate from the thyroid cartilage
o Cricopharyngeal fibres originate from the cricoid cartilage
o All fibres insert posteriorly onto the pharyngeal raphe.
Fig 4 – Lateral view of the deep structures of the pharynx. Visible are the circular muscles of the pharynx,
and the stylopharyngeus.
Longitudinal
The longitudinal muscles are the stylopharyngeus, palatopharyngeus and salpingopharyngeus. They act
to shorten and widen the pharynx, and elevate the larynx during swallowing.
 Stylopharyngeus – originates from the styloid process of the temporal bone and inserts onto the
pharyngeal wall.
o Unlike the other pharyngeal muscles, it is innervated by the glossopharyngeal nerve (CN IX).
 Palatopharyngeus – originates from the hard palate of the oral cavity and inserts onto the pharyngeal
wall.
o Innervated by the vagus nerve (CN X).
 Salpingopharyngeus – originates from the Eustachian tube and inserts onto the pharyngeal wall.
o Innervated by the vagus nerve (CN X).
o In addition to contributing to swallowing, it also opens the Eustachian tube to equalise the
pressure in the middle ear.
Fig 5 – Posterior view of the pharynx. The pharynx has been split down the midline and opened, to show
the longitudinal muscles.
Innervation
Motor and sensory innervation of the majority of the pharynx (except nasopharynx) is achieved by
the pharyngeal plexus.
The pharyngeal plexus, which overlies the middle pharyngeal constrictor, is formed by:
 Pharyngeal branches from the glossopharyngeal nerve (CN IX).

 Pharyngeal branch of the vagus nerve (CN X).
 Branches from the external laryngeal nerve.
 Sympathetic fibres from the superior cervical ganglion.
Sensory
The pharynx receives sensory innervation from the glossopharyngeal nerve.
In addition:
 The anterior and superior aspect of the nasopharynx is innervated by the maxillary nerve (CN V2)
 The inferior aspect of the laryngopharynx (surrounding the beginning of the larynx) is innervated by
the internal branch of the vagus nerve.
Motor
All the muscles of the pharynx are innervated by the vagus nerve (CN X), except for the stylopharyngeus,
which is innervated by the glossopharyngeal nerve (CN IX).
Vasculature
Arterial supply to the pharynx is via branches of the external carotid artery:
 Ascending pharyngeal artery

 Branches of the facial artery
 Branches of the lingual and maxillary arteries.
Venous drainage is achieved by the pharyngeal venous plexus, which drains into the internal jugular
vein.
Fig 6 – Vasculature of the pharynx. Right arterial supply via the ECA and left venous plexus shown.
II. The Larynx

A. The larynx
The Larynx
Last updated: December 31, 2020
Revisions: 51
The larynx (voice box) is an organ located in the anterior neck. It is a component of the respiratory tract,
and has several important functions, including phonation, the cough reflex, and protection of the lower
respiratory tract.
The structure of the larynx is primarily cartilaginous, and is held together by a series of ligaments and
membranes. Internally, the laryngeal muscles move components of the larynx for phonation and breathing.
In this article, we will discuss the anatomy of the larynx – its location, structure, vasculature and
innervation. We shall also consider its clinical relevance.
Anatomical Position and Relations
The larynx is located in the anterior compartment of the neck, suspended from the hyoid bone, and
spanning between C3 and C6. It is continuous inferiorly with the trachea, and opens superiorly into the
laryngeal part of the pharynx.
It is covered anteriorly by the infrahyoid muscles, and laterally by the lobes of the thyroid gland. The
larynx is also closely related to the major blood vessels of neck, which ascend laterally to it.
Posterior to the larynx is the oesophagus. This is of clinical relevance during emergency intubation – as
pressure can be applied to the cricoid cartilage of the larynx to occlude the oesophagus, and thus prevent
regurgitation of gastric contents (known as cricoid pressure or Sellick’s manoeuvre).
Fig 1 -Anatomical position of the larynx (yellow) in the neck. It is continuous with the trachea inferiorly and
the pharynx superiorly.
Anatomical Structure
The larynx is formed by a cartilaginous skeleton, which is held together by ligaments and membranes.
The laryngeal muscles act to move the components of the larynx for phonation and breathing. More
information about each of these structures can be found in their respective sections.
Anatomically, the internal cavity of the larynx can be divided into three sections:
 Supraglottis – From the inferior surface of the epiglottis to the vestibular folds (false vocal cords).
 Glottis – Contains vocal cords and 1cm below them. The opening between the vocal cords is known
as rima glottidis, the size of which is altered by the muscles of phonation.
 Subglottis – From inferior border of the glottis to the inferior border of the cricoid cartilage.
The interior surface of the larynx is lined by pseudostratified ciliated columnar epithelium. An important
exception to this is the true vocal cords, which are lined by a stratified squamous epithelium.
Vasculature
The arterial supply to the larynx is via the superior and inferior laryngeal arteries:
 Superior laryngeal artery – a branch of the superior thyroid artery (derived from the external carotid).
It follows the internal branch of the superior laryngeal nerve into the larynx.
 Inferior laryngeal artery – a branch of the inferior thyroid artery (derived from the thyrocervical
trunk). It follows the recurrent laryngeal nerve into the larynx.
Venous drainage is by the superior and inferior laryngeal veins. The superior laryngeal vein drains to the
internal jugular vein via the superior thyroid, whereas the inferior laryngeal vein drains to the left
brachiocephalic vein via the inferior thyroid vein.
Innervation
The larynx receives both motor and sensory innervation via branches of the vagus nerve:
 Recurrent laryngeal nerve – provides sensory innervation to the infraglottis, and motor innervation to
all the internal muscles of larynx (except the cricothyroid).
 Superior laryngeal nerve – the internal branch provides sensory innervation to the supraglottis, and
the external branch provides motor innervation to the cricothyroid muscle.
By Truth-seeker2004 [CC-BY-SA-3.0], via Wikimedia Commons
Fig 2 – Overview of the major branches of the vagus nerve

Clinical Relevance: Vocal Cord Paralysis
The vocal cords are responsible for the production of speech. Their movement is controlled by the intrinsic
muscles of the larynx – the majority of which are innervated by the recurrent laryngeal nerve (an exception
is the cricothyroid muscle; innervated by the external laryngeal nerve).
Due to its long course, the recurrent laryngeal nerve is susceptible to damage. Causes of RLN palsy
include:
 Apical lung tumour

 Thyroid cancer
 Aortic aneurysm
 Cervical lymphadenopathy
 Iatrogenic (particularly during thyroid surgery due to the close relationship with the inferior thyroid
artery).
In unilateral RLN palsy, one vocal cord is paralysed. The other vocal cord tends to compensate, and
speech is not affected to a great degree, although the patient may experience hoarseness of voice. In
cases of bilateral palsy, both vocal cords are paralysed in a position between adduction and abduction.
Breathing is impaired, and phonation cannot occur.
In situations where the nerves are only partially damaged, the vocal folds become paralysed in a fully
adducted position. If this occurs bilaterally, the rima glottidis (space between the vocal cords) is
completely closed, and emergency surgical intervention is required to restore the airway.
Adobe Stock, Licensed to TeachMeSeries Ltd
Fig 3 – The vocal cords. In bilateral partial recurrent laryngeal palsy, the vocal cords are paralysed in the
fully adducted position.
B. Laryngeal Cartilage
Laryngeal Cartilages
Original Author(s): Oliver Jones and Sam Barnes
Last updated: October 22, 2020
Revisions: 21
respiratory tract.
There are nine cartilages located within the larynx; three unpaired, and six paired. They form the laryngeal
skeleton, which provides rigidity and stability. In this article, we shall examine the anatomy of the laryngeal
cartilages.
Unpaired Cartilages
The three unpaired cartilages are the epiglottis, thyroid and cricoid cartilages.
Thyroid Cartilage
The thyroid cartilage is a large, prominent structure which is easily visible in adult males. It is composed of
two sheets (laminae), which join anteriorly to form the laryngeal prominence (Adam’s apple).
The posterior border of each sheet project superiorly and inferiorly to form the superior and inferior
horns (also known as cornu). The superior horns are connected to the hyoid bone via the lateral thyrohyoid
ligament, while the inferior horns articulate with the cricoid cartilage.
Cricoid Cartilage
The cricoid cartilage is a complete ring of hyaline cartilage, consisting of a broad sheet posteriorly and a
much narrower arch anteriorly (said to resemble a signet ring in shape).
The cartilage completely encircles the airway, marking the inferior border of the larynx at the level of C6. It
articulates with the paired arytenoid cartilages posteriorly, as well as providing an attachment for the
inferior horns of the thyroid cartilage.
The cricoid is the only complete circle of cartilage in the larynx or trachea. This is of clinical relevance
during emergency intubation – as pressure can be applied to the cricoid to occlude the oesophagus, and
thus prevent regurgitation of gastric contents (known as cricoid pressure or Sellick’s manoeuvre).
Epiglottis
The epiglottis is a leaf shaped plate of elastic cartilage which marks the entrance to the larynx. Its ‘stalk’
is attached to the back of the anterior aspect of the thyroid cartilage. During swallowing, the epiglottis
flattens and moves posteriorly to close off the larynx and prevent aspiration.
Fig 1.0 – Structure of the (a) thyroid cartilage and (b) cricoid cartilage.
Paired Cartilages
There are three paired cartilages – the arytenoid, corniculate and cuneiform. They are situated bilaterally in
the larynx.
Arytenoid Cartilages
The arytenoid cartilages are pyramidal shaped structures that sit on the cricoid cartilage. They consist of
an apex, base, three sides and two processes, and provides an attachment point for various key structures
in the larynx:
 Apex – articulates with the corniculate cartilage.
 Base – articulates with the superior border of the cricoid cartilage.
 Vocal process – provides attachment for the vocal ligament.
 Muscular process – provides attachment for the posterior and lateral cricoarytenoid muscles.
Corniculate Cartilages
The corniculate cartilages are minor cartilaginous structures. They articulate with the apices of the
arytenoid cartilages.
Cuneiform Cartilages
The cuneiform cartilages are located within the aryepiglottic folds. They have no direct attachment, but act
to strengthen the folds.

Fig 1.1 – The major cartilages in the laryngeal skeleton.
C. Laryngeal Ligaments and Folds
Laryngeal Ligaments and Folds

Revisions: 30
and has several important functions; including phonation, the cough reflex, and protection of the lower
respiratory tract.
It contains numerous ligaments and folds; the ligaments support the cartilaginous skeleton of the larynx,
whilst the folds are involved in airway protection and phonation.
In this article, we shall look at the anatomy of the laryngeal ligaments and folds.
Membranes and Ligaments
The laryngeal membranes and ligaments support the cartilaginous skeleton of the larynx.
The extrinsic ligaments act to attach the components of the larynx to external structures (such as the
hyoid and the cricoid cartilage). The intrinsic ligaments are responsible for holding the cartilages of the
larynx together as one functional unit internally
Extrinsic:
 Thyrohyoid membrane – Spans between the superior aspect of the thyroid cartilage and the hyoid
bone. It is pierced laterally by the superior laryngeal vessels and internal laryngeal nerve (branch of
the superior laryngeal nerve).
o Median thyrohyoid ligament – Anteromedial thickening of the membrane.
o Lateral thyrohyoid ligaments – Posterolateral thickenings of the membrane.
 Hyo-epiglottic ligament – Connects the hyoid bone to the anterior aspect of the epiglottis.
 Cricotracheal ligament – Connects the cricoid cartilage to the trachea.

 Median cricothyroid ligament – Anteromedial thickening of the cricothyroid ligament (see below),
connecting the thyroid and cricoid cartilages.
Intrinsic:
 Cricothyroid ligament – Originates from the cricoid cartilage and extends superiorly, where it
terminates with an free (unattached) upper margin – which forms the vocal ligament. It is additionally
attached anteriorly to the thyroid cartilage, and posteriorly to the arytenoid cartilage.
 Quadrangular membrane – Spans between the anterolateral arytenoid cartilage and the lateral
aspect of the epiglottis. It has a free upper margin and lower margin. The lower margin is thickened to
become the vestibular ligament.
Fig 1 – Some of the major laryngeal membranes and ligaments. Note that the upper free edge of the
cricothyroid ligament is not demonstrated in this image.
Clinical Relevance: Cricothyroidotomy
A cricothyroidotomy is an emergency procedure to provide a temporary airway. It is typically used in
situations where there is an obstruction at or above the larynx (e.g foreign body, angioedema or facial
trauma), and intubation has been unsuccessful.
To perform the technique, the thyroid cartilage is palpated in the neck – below which there is a depression
representing the cricothyroid ligament. A small incision is made in the midline of this ligament, and an
endotracheal tube is inserted to secure the airway.
Laryngeal Folds
There are two important soft tissue folds located within the larynx – the vestibular folds and vocal folds.
They play a crucial role in protection of the airway, breathing, and phonation.
Vocal Folds
The vocal folds (true vocal cords) are the more important of the two sets. Under the control of the
muscles of phonation, they are abducted, adducted, relaxed and tensed to control the pitch of the sound
created.
Histologically, they are structured as follows (superficial to deep):
 Non-keratinised stratified squamous epithelium – Stratified layer provides extensive protection

against foreign bodies which may accidentally enter the larynx.
 Reinke’s space – This watery, amorphous layer is rich in glycosaminoglycans. Due to its fluidity, the
epithelium is able to vibrate freely above it to create sound.
 Vocal ligament – Lies at the free upper edge of the cricothryoid ligament.
 Vocalis muscle – Exceptionally fine muscle fibres that lie lateral to the vocal ligaments.
The vocal folds are relatively avascular, and appear white in colour. The space between the vocal folds is
known as the rima glottidis.
Fig 3 – The vocal ligament forms from the free upper edge of the cricothyroid ligament.
Vestibular Folds
The vestibular folds (false vocal cords) lie superiorly to the true vocal cords. They consist of the
vestibular ligament (free lower edge of the quadrangular membrane) covered by a mucous membrane, and
are pink in colour. They are fixed folds, which act to provide protection to the larynx.
Fig 4 – The vocal and vestibular folds of the larynx.
D. Laryngeal Muscles
Laryngeal Muscles
.Original Author(s): Oliver Jones and Sam Barnes
Last updated: February 1, 2023
Revisions: 33
respiratory tract.
The muscles of the larynx can be divided into two groups; the external muscles and the internal muscles.
The external muscles act to elevate or depress the larynx during swallowing. In contrast, the internal
muscles act to move the individual components of the larynx – playing a vital role in breathing and
phonation.
In this article, we shall look at the anatomy of the laryngeal muscles – their attachments, innervation and
blood supply.
Extrinsic Muscles
The extrinsic muscles act to move the larynx superiorly and inferiorly. They are comprised of
the suprahyoid and infrahyoid groups, and the stylopharyngeus (a muscle of the pharynx).
The supra- and infrahyoid muscle groups attach to the hyoid bone. This, in turn, is bound to the larynx by
strong ligaments; allowing the whole of the larynx to be moved as one unit.
As a general rule, the suprahyoid muscles and the stylopharyngeus elevate the larynx, whilst the infrahyoid
muscles depress the larynx.

Fig 1 – Anterior view of the neck with the suprahyoid muscles highlighted.
Fig 2 – Anterior view of the infrahyoid muscles of the neck.

Intrinsic Muscles
The intrinsic laryngeal muscles act on the individual components of the larynx. They control the shape of
the rima glottidis (opening between the vocal folds and the arytenoid cartilages), and the length and
tension of the vocal folds.
All the intrinsic muscles of the larynx (except the cricothyroid) are innervated by the inferior laryngeal
nerve – the terminal branch of the recurrent laryngeal nerve, itself a branch of the vagus nerve. The
cricothyroid is innervated by the external branch of the superior laryngeal nerve – again derived from the
vagus nerve.
Cricothyroid
The cricothyroid muscle stretches and tenses the vocal ligaments, and so is important for the creation of
forceful speech. It also has a role in altering the tone of voice (along with the thyroarytenoid muscle), hence
its colloquial name ‘singer’s muscle’.
 Attachments: Originates from the anterolateral aspect of the cricoid cartilage and attaches to the
inferior margin and inferior horn of the thyroid cartilage.
 Actions: Stretches and tenses the vocal ligament.

 Innervation: External laryngeal nerve (branch of superior laryngeal).
Thyroarytenoid
The thyroarytenoid muscle acts to relax the vocal ligament, allowing for a softer voice.
 Attachments: Originates from the inferoposterior aspect of the angle of the thyroid cartilage and
attaches to the anterolateral part of the arytenoid cartilage.
 Actions: Relaxes the vocal ligament.
 Innervation: Inferior laryngeal nerve (branch of recurrent laryngeal).
Fig 2 – Superior view of the intrinsic muscles of the larynx.

Posterior cricoarytenoid
The posterior cricoarytenoid muscles are the sole abductors of the vocal folds, and thus the only muscle
capable of widening the rima glottidis.
 Attachments: Originates from the posterior surface of the cricoid cartilage and attaches to the
muscular process of the arytenoid cartilage.
 Actions: Abduction of the vocal folds.
Lateral cricoarytenoid
The lateral cricoarytenoid muscles are the major adductors of the vocal folds. They narrow the rima
glottidis, modulating the tone and volume of speech.
 Attachments: Originates from the arch of the cricoid cartilage and attaches to the muscular process
of the arytenoid cartilage.
 Actions: Adduction of the vocal folds.
Transverse and Oblique Arytenoids
The transverse and oblique arytenoids muscles adduct the arytenoid cartilages, closing the posterior
portion of rima glottidis. This narrows the laryngeal inlet.
 Attachments: Spans from one arytenoid cartilage to the opposite arytenoid.
 Actions: Adduction of the arytenoid cartilages.
Fig 3 – Posterior view of the intrinsic muscles of the larynx.
III. The Thyroid Gland
The Thyroid Gland

Revisions: 39
The thyroid gland is an endocrine structure located in the neck. It plays a key role in regulating the
metabolic rate of the body.
In this article, we shall look at the anatomy of the thyroid gland – its position, blood supply, and clinical
correlations.
Anatomical Location
The thyroid gland is located in the anterior neck and spans the C5-T1 vertebrae. It consists of two lobes
(left and right), which are connected by a central isthmus anteriorly – this produces a butterfly-shape
appearance.
The lobes of the thyroid gland are wrapped around the cricoid cartilage and superior rings of the trachea.
The gland is located within the visceral compartment of the neck (along with the
trachea, oesophagus and pharynx). This compartment is bound by the pretracheal fascia.

Fig 1 – Overview of the position of the thyroid gland in the neck
Fig 2 – The thyroid gland consists of two lobes connected by a central isthmus. It is wrapped around the
cricoid cartilage and trachea anteriorly.
Clinical Relevance: Thyroglossal Cyst
In the embryo, the thyroid gland begins development near the base of the tongue – in an area known as
the foramen cecum. It descends during development and reaches its destination in the anterior neck by
week 7.
The descent of the developing thyroid gland forms the thyroglossal duct – an epithelialised tract that
connects the gland to its origin at the foramen cecum. It usually regresses by the 10th week of gestation,
but can persist in some individuals. If it fails to regress, the duct can give rise to cysts or fistulae.
A thyroglossal cyst results from a build-up of secretions within the duct. It typically presents as a midline
lump in the anterior neck which rises on tongue protrusion. If left untreated, this cyst can become infected,
and form a cutaneous fistula – discharging out onto the skin of the anterior neck.
Thyroglossal cysts and fistulae are usually treated with complete excision. Recurrence is quoted at
approximately 2.5%.
Anatomical Relations
The thyroid gland is closely associated with numerous other structures in the anterior neck:
 Anteriorly – infrahyoid muscles, namely the sternothyroid, superior belly of the omohyoid and
sternohyoid
 Laterally – carotid sheath, containing the common carotid artey, internal jugular vein and vagus nerve
 Medially –
o Organs – larynx, pharynx, trachea and oesophagus
o Nerves – external laryngeal and recurrent laryngeal
Fig 3 – Transverse section of the neck, showing the pretracheal fascia in red.
Vasculature
The thyroid gland secretes hormones directly into the circulation and is highly vascularised.
Arterial Supply
The arterial supply to the thyroid gland is via two main arteries:
 Superior thyroid artery – arises as the first branch of the external carotid artery. It lies in close
proximity to the external branch of the superior laryngeal nerve (innervates the larynx).
 Inferior thyroid artery – arises from the thyrocervical trunk (a branch of the subclavian artery). It lies
in close proximity to the recurrent laryngeal nerve (innervates the larynx).
In a small proportion of people (around 10%) there is an additional artery present – the thyroid ima artery.
It arises from the brachiocephalic trunk and supplies the anterior surface and isthmus of the thyroid gland.
Venous Drainage
Venous drainage is carried by the superior, middle, and inferior thyroid veins, which form a venous
plexus around the thyroid gland.
The superior and middle veins drain into the internal jugular vein and the inferior empties into the
brachiocephalic vein.
Innervation
The thyroid gland is innervated by branches derived from the sympathetic trunk.
These nerves do not control the secretory function of the gland – the release of thyroid hormones is
regulated by the pituitary gland.
Lymphatic Drainage
The lymphatic drainage of the thyroid is to the paratracheal and deep cervical nodes.
Clinical Relevance: Recurrent Laryngeal Nerve

The left and right recurrent laryngeal nerves lie in close proximity to the thyroid gland and care must be
taken not to damage them during thyroid surgery.
They branch from their respective vagus nerve within the chest and hook around the right subclavian
artery (right RL nerve), or the arch of aorta (left RL nerve).
The recurrent laryngeal nerve then travels back up the neck, running between the trachea and oesophagus
in the tracheoesophageal groove. It then passes underneath the thyroid gland to innervate the larynx.
IV. The Parathyroid Gland
The Parathyroid Glands

1. Home
2. The Neck
3. Viscera of the Neck
4. The Parathyroid Glands
Original Author(s): Vicky Theakston

Last updated: November 12, 2020
Revisions: 19
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The parathyroid glands are endocrine glands located in the anterior neck.
They are responsible for the production of parathyroid hormone (PTH), which acts to increase the level of
serum calcium.
In this article, we shall look at the anatomy of the parathyroid glands – their location, neurovascular
supply, and clinical correlations.
Anatomical Location
The parathyroid glands are usually located on the posterior aspect of the thyroid gland. They are flattened
and oval in shape – situated external to the thyroid gland itself but within the pretracheal fascia.
Most individuals have four parathyroid glands, although variation in number (from two to six) is common:
 Superior parathyroid glands (x2) – derived from the fourth pharyngeal pouch. They are located at
the middle of the posterior border of each thyroid lobe, approximately 1cm superior to the entry of the
inferior thyroid artery into the thyroid gland.
 Inferior parathyroid glands (x2) – derived from the third pharyngeal pouch. Although inconsistent in
location between individuals, the inferior parathyroid glands are usually found near the inferior poles of
the thyroid gland.
In a small number of people, the inferior parathyroid glands can be found as far inferiorly as the superior
mediastinum.
Fig 1 – Posterior aspect of the thyroid gland, demonstrating the most common location of the parathyroid
glands.
Vasculature
The vascular supply is similar to that of the thyroid gland.
Arterial supply is chiefly via the inferior thyroid artery (as this artery supplies the posterior aspect of the
thyroid gland – where the parathyroids are located). Collateral arterial supply is from the superior thyroid
artery and thyroid ima artery.
Venous drainage is into the superior, middle, and inferior thyroid veins.
Lymphatics
The lymphatic drainage from the parathyroid glands is to the paratracheal and deep cervical nodes.
Nerves
The parathyroid glands have an extensive supply of sympathetic nerves derived from thyroid branches of
the cervical ganglia.
Note: these nerves are vasomotor, not secretomotor – endocrine secretion of parathyroid hormone is
under hormonal control.
Clinical Relevance: Parathyroid Glands and Hypocalcaemia

Due to their location on the posterior aspect of thyroid gland, the parathyroid glands are at a high risk of
being damaged or removed inadvertently during thyroid surgery.
This can result in an acute drop in serum calcium – hypocalcaemia. Clinical features include tetany,
muscle cramps and paraesthesia of the fingers, toes, and mouth.
Because of this risk, it is usually standard post-operative practice to check the parathyroid hormone and
serum calcium in all patients following thyroid surgery.
By n.raveender [CC-BY-SA-3.0] via Wikimedia Commons
Fig 2 – During surgery on the thyroid gland, the parathyroid glands must be identified and preserved.
4. Muscles of the Neck
I. The Suboccipital Muscles
The Suboccipital Muscles

1. Home
2. The Neck
4. The Suboccipital Muscles
Original Author(s): Aaron Cassidy

Revisions: 40
The suboccipital muscles are a group of four muscles situated underneath the occipital bone. All the
muscles in this group are innervated by the suboccipital nerve.
They are located within the suboccipital compartment of the neck; deep to the sternocleidomastoid,
trapezius, splenius and semispinalis muscles. They collectively act to extend and rotate the head.
In this article, we shall look at the anatomy of the suboccipital muscles – their attachments, actions and
innervation.
Rectus Capitis Posterior Major
The rectus capitis posterior major is the larger of the rectus capitis muscles. It is located laterally to the
rectus capitis posterior minor.
 Attachments: Originates from the spinous process of the C2 vertebrae (axis) and inserts into the
lateral part of the inferior nuchal line of the occipital bone.
 Actions: Extension and rotation of the head.
 Innervation: Suboccipital nerve (posterior ramus of C1).
Rectus Capitis Posterior Minor

The rectus capitis posterior minor is the most medial of the suboccipital muscles. There is a connective
tissue bridge between this muscle and the dura mater (outer membrane of the meninges) – which may play
a role in cervicogenic headaches.
 Attachments: Originates from the posterior tubercle (a rudimentary spinous process) of the C1
vertebra. Attaches to the medial part of the inferior nuchal line of the occipital bone.
 Actions: Extension of the head.
 Innervation: Suboccipital nerve (posterior ramus of C1).

Fig 1 – The left occipital muscles, which lie underneath the deep muscles of the back.
Obliquus Capitis Inferior
The obliquus capitis inferior is the most inferiorly positioned of the suboccipital muscles. It is the only
muscle within this group which has no attachment to the cranium.
 Attachments: Originates from the spinous process of the C2 vertebra and attaches onto the
transverse process of C1.
 Actions: Extension and rotation of the head.
 Innervation: Suboccipital nerve (posterior ramus of C1)
Obliquus Capitis Superior

The obliquus capitis superior is located laterally in the suboccipital compartment.
 Attachments: Originates from the transverse process of C1 and attaches onto the occipital bone
(between the superior and inferior nuchal lines).
 Actions: Extension of the head.
 Innervation: Suboccipital nerve (posterior ramus of C1)
Suboccipital Triangle
The suboccipital triangle is an area bordered by three of the suboccipital muscles. It contains the
vertebral artery (can be identified during surgery), suboccipital venous plexus and suboccipital nerve. Its
borders are as follows:
 Superomedial: Rectus capitus posterior major

 Superolateral: Obliquus capitus superior
 Inferior: Obliquus capitus inferior
 Floor: Posterior atlanto-occipital membrane and posterior arch of the C1 vertebrae (atlas)
 Roof: Semispinalis capitus
Biodigital Human 2016

Fig 2 – The suboccipital triangle. It can be used to locate the vertebral artery, as shown on this illustration.
II. The Suprahyoid Muscles
The Suprahyoid Muscles

1. Home
2. The Neck
4. The Suprahyoid Muscles

Revisions: 38
The suprahyoid muscles are a group of four muscles located superior to the hyoid bone of the neck. They
all act to elevate the hyoid bone – an action involved in swallowing.
The arterial supply to these muscles is via branches of the facial artery, occipital artery, and lingual artery.
In this article, we shall look at the anatomy of the suprahyoid muscles – their attachments, actions, and
innervation.
Stylohyoid
The stylohyoid muscle is a thin muscular strip, which is located superiorly to the posterior belly of the
digastric muscle.
 Attachments: Arises from the styloid process of the temporal bone and attaches to the lateral
aspect of the hyoid bone.
 Actions: Initiates a swallowing action by pulling the hyoid bone in a posterior and superior direction.
 Innervation: Stylohyoid branch of the facial nerve (CN VII). This arises proximally to the parotid gland.

Fig 1 – Anterior view of the neck with the suprahyoid muscles highlighted.
Digastric
The digastric is comprised of two muscular bellies, which are connected by a tendon. In some cadaveric
specimens, this tendon can be seen to pierce the stylohyoid muscle.
 Attachments:
o The anterior belly arises from the digastric fossa of the mandible.
o The posterior belly arises from the mastoid process of the temporal bone.
o The two bellies are connected by an intermediate tendon, which is attached to the hyoid bone
via a fibrous sling.
 Actions: Depresses the mandible and elevates the hyoid bone.
 Innervation:
o The anterior belly is innervated by the inferior alveolar nerve, a branch of the mandibular nerve
(which is derived from the trigeminal nerve, CN V).
o The posterior belly is innervated by the digastric branch of the facial nerve.
Mylohyoid
The mylohyoid is a broad, triangular shaped muscle. It forms the floor of the oral cavity and supports the
floor of the mouth.
 Attachments: Originates from the mylohyoid line of the mandible, and attaches onto the hyoid bone.
 Actions: Elevates the hyoid bone and the floor of the mouth.
 Innervation: Inferior alveolar nerve, a branch of the mandibular nerve (which is derived from the
trigeminal nerve).
Geniohyoid
The geniohyoid is located either side of the midline of the neck, deep to the mylohyoid muscle
 Attachments: Arises from the inferior mental spine of the mandible. It then travels inferiorly and
posteriorly to attach to the hyoid bone.
 Actions: Depresses the mandible and elevates the hyoid bone.
 Innervation: C1 nerve roots that run within the hypoglossal nerve.
Fig 2 – Lateral view of the neck with three of the suprahyoid muscles highlighted (digastric, mylohyoid and
stylohyoid)
III. The Infrahyoid Muscles
The Infrahyoid Muscles

1. Home
2. The Neck
4. The Infrahyoid Muscles

Revisions: 36
The infrahyoid muscles are a group of four muscles that are located inferiorly to the hyoid bone in the
neck. They can be divided into two groups:
 Superficial plane – omohyoid and sternohyoid muscles.

 Deep plane – sternothyroid and thyrohyoid muscles.
The arterial supply to the infrahyoid muscles is via the superior and inferior thyroid arteries, with venous
drainage via the corresponding veins.
In this article, we shall look at the anatomy of the infrahyoid muscles – their attachments, actions and
innervations.
Omohyoid
The omohyoid is comprised of two muscle bellies, which are connected by a muscular tendon.
 Attachments:
o Superior belly arises from the hyoid bone and inferior belly arises from the scapula.
o Two muscle bellies are connected by an intermediate tendon, which is anchored to the clavicle
by the deep cervical fascia.
 Actions: Depresses the hyoid bone.
 Innervation: Anterior rami of C1-C3, carried by a branch of the ansa cervicalis.
Fig 1 – Lateral view of the infrahyoid muscles of the neck.

Sternohyoid
The sternohyoid muscle is located in the superficial plane of the neck, along with the omohyoid muscle.
 Attachments: Originates from the sternum and sternoclavicular joint. Ascends to insert onto the hyoid
bone.
 Actions: Depresses the hyoid bone.
Sternothyroid
The sternothyroid muscle is a wide muscle, located underneath the sternohyoid in the deep plane of the
neck.
 Attachments: Arises from the manubrium of the sternum and attaches to the thyroid cartilage.
 Actions: Depresses the thyroid cartilage.
Thyrohyoid
The thyrohyoid is a short band of muscle, thought to be a continuation of the sternothyroid muscle.
 Attachments: Arises from the thyroid cartilage of the larynx and ascends to attach to the hyoid bone.
 Actions: Depresses the hyoid. If the hyoid bone is fixed, it can elevate the larynx.
 Innervation: Anterior ramus of C1, carried within the hypoglossal nerve.

Fig 2 – Anterior view of the infrahyoid muscles of the neck.
IV. The Scalene Muscles
The Scalene Muscles

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2. The Neck
4. The Scalene Muscles

Revisions: 26
The scalene muscles are three paired muscles (anterior, middle and posterior), located in the lateral
aspect of the neck. Collectively, they form part of the floor of the posterior triangle of the neck.
The scalenes act as accessory muscles of respiration and perform flexion at the neck.
In this article, we shall look at the anatomy of the scalene muscles – their attachments, function, innervation
and clinical importance.

Fig 1 – The anterior, middle and posterior scalene muscles of the neck
Scalene Muscles
Anterior Scalene
The anterior scalene muscle is located deep to the sternocleidomastoid on the lateral aspect of the neck.
 Attachments: Originates from the anterior tubercles of the transverse processes of C3-C6 and
attaches onto the scalene tubercle (on the inner border of the first rib).
 Function: Elevation of the first rib. Ipsilateral contraction causes ipsilateral lateral flexion of the neck,
and bilateral contraction causes anterior flexion of the neck.
 Innervation: Anterior rami of C5-C6.
Middle Scalene
The middle scalene is the largest and longest of the three scalene muscles. It has several long, thin
muscle bellies arising from the cervical spine, which converge into one large belly that inserts into the first
rib.
 Attachments: Originates from the posterior tubercles of the transverse processes of C2-C7 and
attaches to the scalene tubercle of the first rib.
 Function: Elevation of the first rib. Ipsilateral contraction causes ipsilateral lateral flexion of the neck.
Posterior Scalene
The posterior scalene is the smallest and deepest of the scalene muscles. Unlike the anterior and middle
scalene muscles, it inserts into the second rib.
 Attachments: Originates from the posterior tubercles of the transverse processes of C5-C7 and
attaches into the second rib.
 Function: Elevation of the second rib, and ipsilateral lateral flexion of the neck.
Anatomical Relationships
The scalene muscles are an important part of the anatomy of the neck, with several important structures
located between and around them.
The brachial plexus and subclavian artery pass between the anterior and middle scalene muscles. This
provides an important anatomical landmark in anaesthetics for performing an interscalene block.
The subclavian vein and phrenic nerve pass anteriorly to the anterior scalene – the subclavian vein
courses horizontally across it, while the phrenic nerve runs vertically down the muscle. The subclavian
artery is located posterior to the anterior scalene.
Fig 2 – Proximal portion of the brachial plexus, in the neck.

Clinical Relevance of the Scalene Muscles
Interscalene block
The brachial plexus courses between the bellies of the anterior scalene and middle scalene muscles. In
upper limb surgery, the brachial plexus can be infiltrated with local anaesthetic to avoid the use of a general
anaesthetic – known as an interscalene block.
To do this, local anaesthetic is injected between these muscles at the level of the cricoid cartilage.
Accessory Muscles of Respiration
The scalene muscles collectively act to elevate the first and second ribs, and in doing so they increase
the intrathoracic volume. In patients with respiratory distress, the scalene muscles may be used as
‘accessory muscles of respiration’ to aid with breathing.
By increasing intrathoracic volume, the patient can ventilate their lungs more effectively. However, they are
not required in the respiration of a healthy individual, and so the use of accessory muscles is an important
clinical sign of respiratory distress.
5. Nerves of the Neck

I. The Cervical Plexus
The Cervical Plexus

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2. The Neck
4. The Cervical Plexus
Original Author(s): Shahab Shahid

Last updated: March 5, 2022
Revisions: 41
The cervical plexus is a network of nerve fibres that supplies innervation to some of the structures in the
neck and trunk.
It is located in the posterior triangle of the neck, halfway up the sternocleidomastoid muscle, and within
the prevertebral layer of cervical fascia. The plexus is formed by the anterior rami (divisions) of cervical
spinal nerves C1-C4.
In this article, we shall look at the anatomy of the cervical plexus – its branches, functions and clinical
correlations.
Fig 1 – Anatomical position of the cervical plexus within the neck.

Spinal Nerves
The spinal nerves C1 – C4 form the basis of the cervical plexus.
At each vertebral level, paired spinal nerves leave the spinal cord via the intervertebral foramina of the
vertebral column.
Each nerve then divides into anterior and posterior nerve fibres. The cervical plexus begins as
the anterior fibres of the spinal nerves C1, C2, C3 and C4.
These fibres combine with each other to form the branches of the cervical plexus.
Fig 2 – The spinal cord outflow at each vertebral level.

Branches of the Cervical Plexus
The cervical plexus gives rise to numerous branches which supply structures in the head and neck. They
can broadly be divided into two groups – muscular branches and sensory branches.
We shall now examine these branches in more detail.
Muscular Branches
The muscular branches of the cervical plexus are located deep to the sensory branches. They supply some
of the muscles of the neck, back and the diaphragm.
After arising from the cervical plexus, the muscular branches tend to travel initially in an anteromedial
direction. This is in contrast to the cutaneous branches, which travel posteriorly.
Phrenic Nerve
The phrenic nerve arises from the anterior rami of C3-C5. It provides motor innervation to the diaphragm.
After arising from the cervical plexus, the nerve travels down the surface of the anterior scalene muscle
and enters the thorax. In the thoracic cavity, the nerve descends anteriorly to the root of the lung to reach
the diaphragm.
A good memory aid for the roots of the phrenic nerve is C3,4,5 keeps the diaphragm alive.
Nerves to Geniohyoid and Thyrohyoid
The C1 spinal nerve gives rise to nerves to the geniohyoid (moves the hyoid bone anteriorly and upwards,
expanding the airway) and the thyrohyoid (which depresses the hyoid bone and elevates the larynx).
These nerves travel with the hypoglossal nerve to reach their respective muscles.
Ansa Cervicalis
The ansa cervicalis is a loop of nerves, formed by nerve roots C1-C3. It gives off four muscular branches:
 Superior belly of the omohyoid muscle

 Inferior belly of omohyoid muscle
 Sternohyoid
 Sternothyroid
These muscles (the infrahyoids) act to depress the hyoid bone; an important function for swallowing and
speech.
Other Muscular Branches
Several other minor branches arise from the nerve roots to supply muscles of the neck and back:
 C1-C2: Rectus capitis anterior and lateralis

 C1-C3: Longus capitis
 C2-C3: Contributions to the prevertebral muscles and sternocleidomastoid
 C3-C4: Contributions to the levator scapulae, trapezius and scalenus medius
The middle and anterior scalenus muscles also receive innervation directly from the cervical plexus.

Fig 3 – The branches of the cervical plexus. The smaller branches have been removed for simplicity.
Sensory Branches
The cutaneous branches of the cervical plexus supply the skin of the neck, upper thorax, scalp and ear.
These nerves all enter the skin at the middle of the posterior border of the sternocleidomastoid. This area is
known as the nerve point of the neck (Erb’s point), and is utilised when performing a cervical plexus nerve
block.
Greater Auricular Nerve
The greater auricular nerve is formed by fibres from C2 and C3 roots. It provides sensation to the external
ear and the skin over the parotid gland. It is the largest ascending branch of the plexus.
The nerve also communicates with the auricular branch of the vagus nerve and the posterior auricular
branch of the facial nerve (which innervates some small muscles around the ear).
Transverse Cervical Nerve
The transverse cervical nerve is also formed by fibres from C2 and C3. It curves around the posterior
aspect of the sternocleidomastoid, and supplies sensation to the anterior neck. The nerve then pierces
the deep cervical fascia and then gives branches that pass superiorly and inferiorly to supply the
anterolateral skin of the neck and upper sternum.
Lesser Occipital Nerve
The lesser occipital nerve is derived from the C2 root, with a contribution from C3 in some individuals. It
supplies cutaneous sensation to the posterosuperior scalp, and commonly communicates with the
posterior branch of the greater auricular nerve.
After its formation, the nerve curves around the accessory nerve, and passes superiorly, close to the
posterior border of the sternocleidomastoid.
Supraclavicular Nerves
The supraclavicular nerves are a group of nerves formed from the C3 and C4 roots.
They arise from the behind the posterior border of sternocleidomastoid, and provide sensation to the skin
overlying the supraclavicular fossa and upper thoracic region and sternoclavicular joint.
Clinical Relevance - Cervical Plexus Block

A cervical plexus block is used to provide regional anaesthesia, usually for surgery in the neck region –
such as carotid endarterectomy, thyroidectomy and cervical lymph node excision.
The anaesthetist inserts the needle containing the local anaesthetic, midway up the posterior border of
the sternocleidomastoid (the nerve point of the neck). They then proceed to inject three times in a fan like
fashion, with the needle pointing cranially, caudally and then anteriorly.
Note: as this procedure can also affect the phrenic nerve, it is usually not performed on those with co-
existing cardiac or respiratory disease.

Fig 4 – The nerve point of the neck, where many cutaneous branches emerge.
II. The Phrenic Nerve
The Phrenic Nerve

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2. The Neck
4. The Phrenic Nerve
Original Author(s): Darren Puttock

Revisions: 29
The phrenic nerve is a bilateral, mixed nerve that originates from the cervical nerves in the neck and
descends through the thorax to innervate the diaphragm.
It is the only source of motor innervation to the diaphragm and therefore plays a crucial role in breathing.
In this article, we shall look at the anatomy of the phrenic nerve – its anatomical course, motor and
sensory functions.
Overview
 Nerve roots – anterior rami of C3, C4 and C5.
 Motor functions – innervates the diaphragm.
 Sensory functions – innervates the central part of the diaphragm, the pericardium and the
mediastinal part of the parietal pleura.
Anatomical Course
The phrenic nerve originates from cervical spinal roots C3, C4 and C5 . This can be remembered using
the limerick “C3, 4 and 5 keep the diaphragm alive”. Spinal root C4 provides the main contribution, with
lesser contributions from C3 and C5 and some communicating fibres from the cervical plexus.
The nerve arises at the lateral border of the anterior scalene muscle. It then passes inferiorly over the
anterior surface of anterior scalene, deep to the prevertebral layer of cervical fascia. On both sides, the
nerve runs posterior to the subclavian vein. From here, the course of the phrenic nerve differs between the
left and right:
Right Phrenic Nerve
 Passes anteriorly over the lateral part of the right subclavian artery.
 Enters the thorax via the superior thoracic aperture.
 Descends anteriorly along the right lung root.
 Courses along the pericardium of the right atrium of the heart.
 Pierces the diaphragm at the inferior vena cava opening.
 Innervates the inferior surface of the diaphragm.
Left Phrenic Nerve
 Passes anteriorly over the medial part of the left subclavian artery.
 Enters the thorax via the superior thoracic aperture.
 Descends anterior to the left lung root.
 Crosses the aortic arch and bypasses the vagus nerve.
 Courses along the pericardium of the left ventricle.
 Pierces and innervates the inferior surface of the diaphragm.
Fig 1 – The origin of the phrenic nerve from the anterior rami of C3,4 and 5.
Motor Functions
The phrenic nerve provides motor innervation to the diaphragm; the main muscle of respiration.
As the phrenic nerve is a bilateral structure, each nerve supplies the ipsilateral side of the diaphragm (the
hemi-diaphragm on the same side as itself).
Sensory Functions
Sensory fibres from the phrenic nerve supply the central part of the diaphragm, including
the surrounding pleura and peritoneum. The nerve also supplies sensation to the mediastinal pleura and
the pericardium.
Fig 2 – The anatomical course of the phrenic nerves, which innervate the diaphragm.
Clinical Relevance: Diaphragmatic Paralysis
The phrenic nerve provides motor innervation to the diaphragm. If the nerve becomes damaged, paralysis
of the diaphragm can result. Causes of phrenic nerve palsy include:
 Mechanical trauma – ligation or damage to the nerve during surgery.

 Compression – due to a tumour within the chest cavity.
 Neuropathies – such diabetic neuropathy.
Paralysis of the diaphragm produces a paradoxical movement. The affected side of the diaphragm moves
upwards during inspiration, and downwards during expiration. A unilateral diaphragmatic paralysis is
usually asymptomatic and is most often an incidental finding on x-ray. If both sides are paralysed, the
patient may experience poor exercise tolerance, orthopnoea and fatigue. Lung function tests will show
a restrictive deficit.
Management of diaphragmatic paralysis is two-fold. Firstly, the underlying cause must be identified and
treated (if possible). The second part of treatment deals with symptomatic relief. This is usually via non-
invasive ventilation, such as a CPAP (continuous positive airway pressure).
By Ratnayake et al [CC BY 2.0] via BioMed Central Ltd

Fig 3 – Chest x-ray, showing paralysis of the right hemidiaphragm.
6. Blood Vessels and Lymphatics of the Head and Neck

I. Major Arteries of the Head and Neck
Major Arteries of the Head and Neck

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2. The Neck
4. Major Arteries of the Head and Neck

Last updated: July 1, 2023
Revisions: 47
The head and neck receives the majority of its blood supply through the carotid and vertebral arteries. This
article shall explore the anatomy of this arterial system – its anatomical course, branches, and clinical
correlations.
Carotid Arteries
We shall start at the origin of the carotid arteries. The right common carotid artery arises from
a bifurcation of the brachiocephalic trunk (the right subclavian artery is the other branch). This
bifurcation occurs roughly at the level of the right sternoclavicular joint.
The left common carotid artery branches directly from the arch of aorta. The left and right common carotid
arteries ascend up the neck, lateral to the trachea and the oesophagus. They do not give off any branches
in the neck.
At the level of the superior margin of the thyroid cartilage (C4), the carotid arteries split into
the external and internal carotid arteries. This bifurcation occurs in an anatomical area known as
the carotid triangle.
The common carotid and internal carotid are slightly dilated here, this area is known as the carotid sinus,
and is important in detecting and regulating blood pressure.
Fig 1.0 – Origin of the blood vessels of the upper limb. Note how the left common carotid and subclavian
arteries arise directly from the arch of aorta.
Fig 1.1 – Lateral vein of the neck, showing the origin and bifurcation of the common carotid artery.
Clinical Relevance: Carotid Sinus Hypersensitivity
The carotid sinus is a dilated portion of the common carotid artery and proximal internal carotid artery. It
contains specialised sensory cells known as baroreceptors. These cells detect stretch as a measure of
blood pressure. The glossopharyngeal nerve feeds this information to the brain, and this is used to regulate
blood pressure.
In some individuals, the baroreceptors are hypersensitive to stretch. External pressure on the carotid
sinus can cause slowing of the heart rate and a decrease in blood pressure. The brain becomes under-
perfused and syncope results. In such patients, checking the pulse at the carotid triangle is not advised.
External to the carotid sinus, there is a cluster of nervous cells known as the carotid body. These cells act
as peripheral chemoreceptors; detecting the O2 content of the blood and relaying this information to the
brain to regulate breathing rate.
External Carotid Artery
The external carotid artery supplies the areas of the head and neck external to the cranium. After arising
from the common carotid artery, it travels up the neck, passing posteriorly to the mandibular neck and
anteriorly to the lobule of the ear.
The artery ends within the parotid gland by dividing into the superficial temporal artery and the maxillary
artery. It gives rise to six branches in total:
 Superior thyroid artery

 Lingual artery
 Facial artery
 Ascending pharyngeal artery
 Occipital artery
 Posterior auricular artery
The facial, maxillary and superficial temporal arteries are the major branches of note. The maxillary artery
supplies the deep structures of the face, while the facial and superficial temporal arteries generally supply
superficial areas of the face.
Clinical Relevance: Blood Supply to the Scalp
The posterior auricular, occipital and superficial temporal arteries (along with two branches of the
internal carotid artery; supra-orbital and supratrochlear) combine to provide a dense blood supply to the
scalp. Injuries to the scalp can cause excessive bleeding for various reasons:
 The walls of the arteries are tightly and closely bound to the underlying connective tissue of the
scalp. This prevents them from constricting to limit blood loss following injury or laceration.
 The numerous anastomoses formed by the arteries produce a very densely vascularised area.
 Deep lacerations can involve the epicranial aponeurosis, which is worsened by the opposing pulls of
the occipital and frontalis muscles.
Despite the possible heavy bleeding, it is important to note that the bony skull gets its blood from
an alternative source (middle meningeal artery), and so will not undergo avascular necrosis.
Fig 1.2 – Blood supply to the superficial structures of the face. Note the maxillary artery before it disappears
into the pterygopalatine fossa, to supply the deep structures of the face.
Clinical Relevance: Extradural Haematoma
The middle meningeal artery is a branch of the maxillary artery. It is unique as it supplies some
intracranial structures (remember, the external carotid artery and its branches usually supply extra-
cranial structures).
The middle meningeal artery supplies the skull and the dura mater (the outer membranous layer covering
the brain). A fracture of the skull at its weakest point, the pterion, can injure or completely lacerate the
MMA. Blood will then collect in between the dura mater and the skull, causing a dangerous increase in
intra-cranial pressure. This is known as an extradural haematoma.
The increase in intra-cranial pressure causes a variety of symptoms: nausea, vomiting, seizures,
bradycardia and limb weakness. It is treated by diuretics in minor cases, and drilling burr holes into the
skull the more extreme haemorrhages.
Fig 1.3 – Lateral view of the skull, showing the path of the meningeal arteries. Note the pterion, a weak
point of the skull, where the anterior middle meningeal artery is at risk of damage.
Internal Carotid Artery
The internal carotid arteries do not supply any structures in the neck, entering the cranial cavity via
the carotid canal in the petrous part of the temporal bone. Within the cranial cavity, the internal carotid
artery supplies:
 The brain
 Eyes
 Forehead
Clinical Relevance: Atherosclerosis of the Carotid Arteries
The swelling at the bifurcation of the common carotid arteries, the carotid sinus, produces turbulent blood
flow. This increases the risk of atheroma formation in this area, with the internal carotid most susceptible.
Atherosclerotic thickening of the tunica intima of these arteries will reduce blood flow to the brain,
resulting in the variety of neurological symptoms; headache, dizziness, muscular weakness. If blood flow
is completely occluded, a cerebral ischaemia (stroke) results.
If atherosclerosis of the carotid arteries is suspected, a Doppler study can be used to assess the severity
of any thickening. In severe cases, the artery can be opened, and the atheromatous tunica intima removed.
This procedure is called a carotid endarterectomy.
Vertebral Arteries
Fig 1.4 – Blood supply to the brain via the vertebral arteries
The vertebral arteries are paired vessels which arise from the subclavian arteries, just medial to the
anterior scalenes. They ascend the posterior aspect of the neck, passing through holes in the transverse
processes of the cervical vertebrae (known as foramen transversarium).
The vertebral arteries enter the cranium via the foramen magnum and converge to form the basilar artery
– which continues to supply the brain. The vertebral arteries do not supply any branches to the neck or
other extra-cranial structures.
Other Arteries of the Neck
The neck is supplied by arteries other than the carotids. The right and left subclavian arteries give rise to
the thyrocervical trunk. From this trunk, several vessels arise, which go on to supply the neck.
 The first branch of the thyrocervical trunk is the inferior thyroid artery. It supplies the thyroid gland
 The ascending cervical artery arises from the inferior thyroid artery, as it turns medially in the neck.
This vessel supplies the posterior prevertebral muscles.
 The transverse cervical artery is the next branch off the thyrocervical trunk. It crosses the base of
the carotid triangle and supplies the trapezius and rhomboid muscles.
 Lastly, the suprascapular artery arises. It supplies the posterior shoulder area.
Fig 1.5 – Lateral view of the neck, showing the thyrocervical trunk
II. Venous Drainage of the Head and Neck
Venous Drainage of the Head and Neck

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2. The Neck
4. Venous Drainage of the Head and Neck

Revisions: 46
The veins of the head and neck collect deoxygenated blood and return it to the heart. Anatomically, the
venous drainage can be divided into three parts:
 Venous drainage of the brain and meninges: Supplied by the dural venous sinuses.
 Venous drainage of the scalp and face: Drained by veins synonymous with the arteries of the
face and scalp. These empty into the internal and external jugular veins.
 Venous drainage of the neck: Carried out by the anterior jugular veins.
In this article, we shall look at the veins mentioned above, their anatomical course, and any clinical
correlations.
Jugular Veins
There are three main jugular veins – external, internal and anterior. They are ultimately responsible for the
venous drainage of the whole head and neck.
External Jugular Vein
The external jugular vein and its tributaries supply the majority of the external face. It is formed by the
union of two veins:
 Posterior auricular vein – drains the area of scalp superior and posterior to the outer ear.
 Retromandibular vein (posterior branch) – itself formed by the maxillary and superficial temporal
veins, which drain the face.
These two veins combine immediately posterior to the angle of mandible, and inferior to the outer ear,
forming the external jugular vein.
After formation, the external jugular vein descends down the neck within the superficial fascia. It runs
anteriorly to the sternocleidomastoid muscle, crossing it in an oblique, posterior and inferior direction.
In the root of the neck, the vein passes underneath the clavicle, and terminates by draining into
the subclavian vein. Along its route down the neck, the EJV receives tributary veins – posterior external
jugular, transverse cervical and suprascapular veins.

Fig 1 – Major tributaries of the external jugular vein, draining the external face and scalp. The facial and
internal jugular veins are labelled for completeness
Clinical Relevance: Severance of the External Jugular Vein
The external jugular vein has a relatively superficial course down the neck, leaving it vulnerable to
damage.
If it is severed, in an injury such as a knife slash, its lumen is held open – this is due to the thick layer
of investing fascia (for more information see Fascial Layers of the Neck). Air will be drawn into the vein,
producing cyanosis, and can stop blood flow through the right atrium. This is a medical emergency,
managed by the application of pressure to the wound – stopping the bleeding, and the entry of air.
Anterior Jugular Veins
The anterior jugular veins vary from person to person. They are paired veins, which drain the anterior
aspect of the neck. Often they will communicate via a jugular venous arch. The anterior jugular veins
descend down the midline of the neck, emptying into the subclavian vein.

Fig 2 – Anterior view of the neck, showing the jugular veins
Internal Jugular Vein
The internal jugular vein (IJV) begins in the cranial cavity as a continuation of the sigmoid sinus. The
initial part of the internal jugular vein is dilated and is known as the superior bulb. It exits the skull via the
jugular foramen.
In the neck, the internal jugular vein descends within the carotid sheath, deep to the sternocleidomastoid
muscle and lateral to the common carotid artery. At the base of the neck, posteriorly to the sternal end of
the clavicle, the IJV combines with the subclavian vein to form the brachiocephalic vein. Immediately prior
to this, the inferior end of internal jugular vein dilates to form the inferior bulb. It has a valve that stops back-
flow of blood.
During its descent down the neck, the internal jugular vein receives blood from
the facial, lingual, occipital, superior and middle thyroid veins. These veins drain blood from the anterior
face, trachea, thyroid, oesophagus, larynx, and muscles of the neck.
Fig 3 – The internal jugular vein and the formation of the brachiocephalic vein
Clinical Relevance: Jugular Venous Pressure
In clinical practice, the internal jugular vein can be observed for pulsations – the nature of which provide
an estimation of right atrial pressure.
When the heart contracts, a pressure wave passes upwards, which can be observed. There are
no valves in the brachiocephalic or subclavian veins – so the pulsations are a fairly accurate indication of
right atrial pressure
Dural Venous Sinuses

The dural venous sinuses are spaces between the periosteal and meningeal layers of dura mater, which
are lined by endothelial cells. They collect venous blood from the veins that drain the brain and bony skull,
and ultimately drain into the internal jugular vein.
Clinical Relevance: Cavernous Sinus
The cavernous sinuses are a clinically important pair of dural sinuses. They are located next to the lateral
aspect of the body of the sphenoid bone. This sinus receives blood from the superior and
inferior ophthalmic veins, the middle superficial cerebral veins, and from another dural venous sinus;
the sphenoparietal sinus.
Located within the cavernous sinus is the internal carotid artery, which crosses the sinus. This allows
for cooling of the arterial blood before it reaches the brain. Along with the internal carotid artery,
the abducens (VI) nerve crosses the sinus. Several nerves are located within the lateral wall of each
sinus; oculomotor (III), trochlear (IV), ophthalmic (V1) and maxillary (V2) nerves.
If the cavernous sinus becomes infected, these nerves are at risk of damage. The facial vein is connected
to cavernous sinus via the superior ophthalmic vein. The facial vein is valveless – blood can reverse
direction and flow from the facial vein to the cavernous sinus. This provides a potential pathway by which
infection of the face can spread to the venous sinuses.
Fig 4 – Coronal section demonstrating the contents of the right cavernous sinus.
III. Lymphatic Drainage of the Head and Neck
Lymphatic Drainage of the Head and Neck

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2. The Neck
4. Lymphatic Drainage of the Head and Neck
Original Author(s): Grace Fitzgerald
Revisions: 32
The lymphatic system functions to drain tissue fluid, plasma proteins and other cellular debris back into the
blood stream, and is also involved in immune defence. Once this collection of substances enters the
lymphatic vessels, it is known as lymph. Lymph is subsequently filtered by lymph nodes and directed into
the venous system.
This article will explore the anatomy of lymphatic drainage throughout the head and neck, and how this is
relevant clinically. We will also look at Waldeyer’s ring, the collection of lymphatic tissue surrounding the
superior pharynx.
Lymphatic Vessels
The lymphatic vessels of the head and neck can be divided into two major groups; superficial vessels and
deep vessels.
Superficial Vessels
The superficial vessels drain lymph from the scalp, face and neck into the superficial ring of lymph nodes
at the junction of the neck and head.
Deep Vessels
The deep lymphatic vessels of the head and neck arise from the deep cervical lymph nodes. They
converge to form the left and right jugular lymphatic trunks:
 Left jugular lymphatic trunk – combines with the thoracic duct at the root of the neck. This empties
into the venous system via the left subclavian vein.
 Right jugular lymphatic trunk – forms the right lymphatic duct at the root of the neck. This empties
into the venous system via the right subclavian vein.
Lymph Nodes
The lymph nodes of the head and neck can be divided into two groups; a superficial ring of lymph nodes,
and a vertical group of deep lymph nodes.
Superficial Lymph Nodes
The superficial lymph nodes of the head and neck receive lymph from the scalp, face and neck. They are
arranged in a ring shape; extending from underneath the chin, to the posterior aspect of the head. They
ultimately drain into the deep lymph nodes.
 Occipital: There are usually between 1-3 occipital lymph nodes. They are located in the back of the
head at the lateral border of the trapezius muscle and collect lymph from the occipital area of the
scalp.
 Mastoid: There are usually 2 mastoid lymph nodes, which are also called the post-auricular lymph
nodes. They are located posterior to the ear and lie on the insertion of the sternocleidomastoid muscle
into the mastoid process. They collect lymph from the posterior neck, upper ear and the back of the
external auditory meatus (the ear canal).
 Pre-auricular: There are usually between 1-3 pre-auricular lymph nodes. They are located anterior to
the auricle of the ear, and collect lymph from the superficial areas of the face and temporal region.
 Parotid: The parotid lymph nodes are a small group of nodes located superficially to the parotid gland.
They collect lymph from the nose, the nasal cavity, the external acoustic meatus, the tympanic cavity
and the lateral borders of the orbit. There are also parotid lymph nodes deep to the parotid gland that
drain the nasal cavities and the nasopharynx.
 Submental: These lymph nodes are located superficially to the mylohoid muscle. They collect lymph
from the central lower lip, the floor of the mouth and the apex of the tongue.
 Submandibular: There are usually between 3-6 submandibular nodes. They are located below the
mandible in the submandibular triangle and collect lymph from the cheeks, the lateral aspects of the
nose, upper lip, lateral parts of the lower lip, gums and the anterior tongue. They also receive lymph
from the submental and facial lymph nodes.
 Facial: This group comprises the maxillary/infraorbital, buccinator and supramandibular lymph nodes.
They collect lymph from the mucous membranes of the nose and cheek, eyelids and conjunctiva.
 Superficial Cervical: The superficial cervical lymph nodes can be divided into the superficial anterior
cervical nodes and the posterior lateral superficial cervical lymph nodes. The anterior nodes lie close
to the anterior jugular vein and collect lymph from the superficial surfaces of the anterior neck. The
posterior lateral nodes lie close to the external jugular vein and collect lymph from superficial
surfaces of the neck.
Fig 1 – The superficial and deep lymph nodes of the head and neck.
Deep Lymph Nodes
The deep (cervical) lymph nodes receive all of the lymph from the head and neck – either directly or
indirectly via the superficial lymph nodes. They are organised into a vertical chain, located within close
proximity to the internal jugular vein within the carotid sheath. The efferent vessels from the deep cervical
lymph nodes converge to form the jugular lymphatic trunks.
The nodes can be divided into superior and inferior deep cervical lymph nodes. They are numerous in
number, but include the prelaryngeal, pretracheal, paratracheal, retropharyngeal, infrahyoid, jugulodigastric
(tonsilar), jugulo-omohyoid and supraclavicular nodes.
Clinical Relevance: Virchow’s Node
Virchow’s node is a supraclavicular node, located in the left supraclavicular fossa (located immediately
superior to the clavicle). It receives lymph drainage from the abdominal cavity.
The finding of an enlarged Virchow’s node is referred to as Troisier’s sign – and indicates of the presence
of cancer in the abdomen, specifically gastric cancer, that has spread through the lymph vessels.
Waldeyer’s Ring
Waldeyer’s tonsillar ring refers to the collection of lymphatic tissue surrounding the superior
pharynx. This lymphatic tissue responds to pathogens that may be ingested or inhaled. The tonsils that
make up the ring are as follows:
 Lingual tonsil – located on the posterior base of the tongue to form the antero-inferior part of the ring.
 Palatine tonsils – located on each side between the palatoglossal and palatopharyngeal arches.
These are the common ‘tonsils’ that can be seen within the oral cavity. They form the lateral part of the
ring.
 Tubal tonsils – these are located where each Eustachian tube opens into the nasopharynx and form
the lateral part of the ring.
 Pharyngeal tonsil – also called the nasopharyngeal/adenoid tonsil, located in the roof of the
nasopharynx, behind the uvulva and forms the postero-superior part of the ring.
Clinical Relevance: Inflamed Palatine Tonsils (Tonsillitis)
The palatine tonsils can become inflamed due to a viral or bacterial infection. In such a case, they appear
red and enlarged, and are accompanied by enlarged jugulo-digastric lymph nodes.
Chronic infection of the palatine tonsils can be treated with their removal, a tonsillectomy. When
performing a tonsillectomy, there may be bleeding primarily from the external palatine vein and
secondarily from the tonsilar branch of the facial artery.
If an infection spreads to the peritonsillar tissue, it can cause abscess formation. This can cause
deviation of the uvula, known as quinsy. A quinsy is a medical emergency, as it can potentially cause
obstruction of the pharynx. It is treated with draining of the abscess and antibiotics.
By James Heilman, MD [CC-BY-SA-3.0], via Wikimedia Commons
Fig 2 – Quinsy – inflammation of the peritonsillar tissue. Note also how the uvula has deviated to the right
as a result of the inflammation.
Lymphatics of the Brain
It was thought that lymphatics were absent from the brain until in 2015, scientists located lymphatic vessels
in the brains of mice and subsequently humans. Work is underway to determine and describe the lymphatic
vessels involved.
7. Other
I. Fascial Layers of the Neck
Fascial Layers of the Neck

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2. The Neck
3. Other
4. Fascial Layers of the Neck

Revisions: 38
Fascia is an internal connective tissue which forms bands or sheets that surround and support muscles,
vessels and nerves in the body.
In the neck, these layers of fascia not only act to support internal structures, but also help
to compartmentalise structures of the neck. There are two fascias in the neck – the superficial cervical
fascia and the deep cervical fascia.
In this article, we shall look at the anatomy of the fascial layers of the neck – their attachments, anatomical
relationships and their clinical relevance.
Superficial Cervical Fascia
The superficial cervical fascia lies between the dermis and the deep cervical fascia. It contains numerous
structures:
 Neurovascular supply to the skin

 Superficial veins (e.g. the external jugular vein)
 Superficial lymph nodes
 Fat
 Platysma muscle
Platysma
The superficial cervical fascia blends with the ‘paper thin’ platysma muscle. The platysma is a broad
superficial muscle which lies anteriorly in the neck.
It has two heads, which originate from the fascia of the pectoralis major and deltoid. The fibres from the two
heads cross the clavicle, and meet in the midline, fusing with the muscles of the face. Superiorly, the
platysma inserts into the inferior border of the mandible.
Innervation to the platysma is via the cervical branch of the facial nerve.

Fig 1 – The platysma muscle, located within the superficial cervical fascia.
Deep Cervical Fascia
The deep cervical fascia lies, as its name suggests, ‘deep’ to the superficial fascia and platysma muscle.
This fascia is organised into several layers. These layers act like a shirt collar, supporting the structures
and vessels of the neck.
We shall now look at the layers of the deep cervical fascia in more detail (superficial to deep):
Investing Layer
The investing layer is the most superficial of the deep cervical fascia.
It surrounds all the structures in the neck. Where it meets the trapezius and sternocleidomastoid muscles,
it splits into two, completely surrounding them.
The investing fascia can be thought of as a tube; with superior, inferior, anterior and posterior attachments:
 Superior – attaches to the external occipital protuberance and the superior nuchal line of the skull.
 Anteriorly – attaches to the hyoid bone.
 Inferiorly – attaches to the spine and acromion of the scapula, the clavicle, and the manubrium of the
sternum.
 Posterior – attaches along the nuchal ligament of the vertebral column

Fig 2 – Transverse section of the neck, with the investing layer of fascia highlighted in blue.
Pretracheal Layer
The pretracheal layer of fascia is situated in the anterior neck. It spans between the hyoid bone superiorly
and the thorax inferiorly (where it fuses with the pericardium).
The trachea, oesophagus, thyroid gland and infrahyoid muscles are enclosed by the pretracheal fascia.
Anatomically, it can be divided into two parts:
 Muscular part – encloses the infrahyoid muscles.

 Visceral part – encloses the thyroid gland, trachea and oesophagus.
The posterior aspect of the visceral fascia is formed by contributions from the buccopharyngeal fascia (a
fascial covering of the pharynx).

Fig 3 – Transverse section of the neck, showing the pretracheal fascia in red.
Prevertebral Layer
The prevertebral fascia surrounds the vertebral column and its associated muscles; scalene muscles,
prevertebral muscles, and the deep muscles of the back.
It has attachments along the antero-posterior and supero-inferior axes:
 Superior attachment – base of the skull.

 Anterior attachment – transverse processes and vertebral bodies of the vertebral column.
 Posterior attachment – along the nuchal ligament of the vertebral column
 Inferior attachment – fusion with the endothoracic fascia of the ribcage.
The anterolateral portion of prevertebral fascia forms the floor of the posterior triangle of the neck. It also
surrounds the brachial plexus as it leaves the neck and subclavian artery as it passes through the lower
neck region – in doing so, it forms the axillary sheath.

Fig 4 – The carotid sheath and prevertebral fascia of the neck.
Carotid Sheath
The carotid sheaths are paired structures on either side of the neck, which enclose an important
neurovascular bundle of the neck.
The contents of the carotid sheath are:
 Common carotid artery

 Internal jugular vein.
 Vagus nerve.
 Accompanying cervical lymph nodes.
The fascia of the carotid sheath is formed by contributions from the pretracheal, prevertebral, and
investing fascia layers. The carotid artery bifurcates within the sheath into the external and internal carotid
arteries.
The carotid fascia is organised into a column, which runs between the base of the skull to the thoracic
mediastinum. This is of clinical importance as a pathway for the spread of infection.
Clinical Relevance: Fascial Spaces of the Neck

The neck fascia compartmentalises structures within the neck. These layers of tough fascia can limit the
spread of infection (for example, a superficial skin abscess may be prevented from spreading deeper into
the neck by the investing fascia).
However, infections that reach the potential spaces between the neck fascia have a well-defined spread:
 Retropharyngeal space – located between the buccopharyngeal fascia (posterior aspect of the
visceral pretracheal fascia) and the prevertebral fascia.
o Extends from the base of the skull to the posterior mediastinum.
 Visceral space – enclosed by the visceral pretracheal fascia.
o Extends from the hyoid bone to the superior mediastinum.
II. The Tonsils (Waldeyer’s Ring)
The Tonsils (Waldeyer’s Ring)

1. Home
2. The Neck
3. Other
4. The Tonsils (Waldeyer’s Ring)
Original Author(s): Smrithi Santhosh

Last updated: December 19, 2022
Revisions: 28
The tonsils are collections of lymphatic tissue located within the pharynx. They collectively form a ringed
arrangement, known as Waldeyer’s ring:
 Pharyngeal tonsil
 Tubal tonsils (x2)
 Palatine tonsils (x2)
 Lingual tonsil
The tonsils are classified as mucosa-associated lymphoid tissue (MALT), and therefore contain T cells,
B cells and macrophages. They have an important role in fighting infection – the first line of defence
against pathogens entering through the nasopharynx or oropharynx.
In this article, we shall look at the anatomy of the tonsils – their location, blood supply and any clinical
correlations.

Fig 1 – The four tonsils that comprise Waldeyer’s ring.
Lingual Tonsil
The lingual tonsil refers to numerous lymphoid nodules located within the submucosa of the posterior third
of the tongue.
This tonsil is responsible for the irregular appearance of the posterior tongue surface. and forms
the inferior part of Waldeyer’s ring.
Like the rest of the tongue, the lingual tonsil is covered by a stratified non-keratinised squamous epithelium.
Blood Supply and Innervation
The arterial supply to the lingual tonsil is largely via the lingual artery, with contributions from the tonsillar
branch of the facial artery and the ascending pharyngeal artery.
The dorsal lingual branch of the lingual vein performs the venous drainage.
Innervation is from the glossopharyngeal nerve.
Lymphatic Drainage
Lymphatic fluid from the lingual tonsil drains into the jugulodigastric and deep cervical lymph nodes.
Adapted from work by OpenStax College [CC BY 3.0]

Fig 2 – The lingual and palatine tonsils.
Pharyngeal Tonsil
The pharyngeal tonsil refers to a collection of lymphoid tissue within the mucosa of the roof of the
nasopharynx. When enlarged, the pharyngeal tonsil is also known as the adenoids.
It is located in the midline of the nasopharynx, and forms the superior aspect of Waldeyer’s ring.
The epithelial covering of the pharyngeal tonsil is ciliated pseudostratified epithelium.
The pharyngeal tonsil receives arterial supply from several vessels:
 Ascending palatine artery

 Ascending pharyngeal artery (external carotid)
 Pharyngeal branch of the maxillary artery
 Artery of the pterygoid canal
 Basisphenoid artery
 Tonsillar branch of the facial artery
Venous drainage is via numerous small veins which pierce the superior constrictor muscle to empty into
the pharyngeal plexus.
The pharyngeal tonsil receives nerve fibres from the vagus and glossopharyngeal cranial nerves.
Lymphatic Drainage
Lymphatic fluid from the pharyngeal tonsil drains into the retropharyngeal nodes (which empty into the deep
cervical chain), and directly into deep cervical nodes within the parapharyngeal space.
Tubal Tonsils
The tubal tonsils refer to lymphoid tissue around the opening of the Eustachian tube in the lateral wall of
the nasopharynx. They form the lateral aspect of the Waldeyer’s ring.
The epithelial covering of the tubal tonsils is ciliated pseudostratified epithelium.
The neurovascular supply is similar to other structures in the nasopharynx. Arterial supply is chiefly via
the ascending pharyngeal artery and venous drainage is to the pharyngeal plexus.
Innervation is via the maxillary and glossopharyngeal nerves.
Lymphatic Drainage
The retropharyngeal and the deep cervical lymph nodes drain the tubal tonsils.
Palatine Tonsils
The palatine tonsils are commonly referred to as ‘the tonsils‘.
They are located within the tonsillar bed of the lateral oropharynx wall – between the palatoglossal arch
(anteriorly) and palatopharyngeal arch (posteriorly). They form the lateral part of the Waldeyer’s ring.
Each tonsil has free medial surface which projects into the pharynx. The lateral surface is covered by a
fibrous capsule, and is separated from the superior constrictor of the tonsillar bed by loose areolar
connective tissue.
They are covered by a stratified non-keratinised squamous epithelium.

Fig 3 – Location of the palatine tonsil in the oropharynx
The arterial supply to the tonsil is via the tonsillar branch of the facial artery. It pierces the superior
constrictor muscle to reach the palatine tonsil.
The venous drainage is via the external palatine vein (drains into the facial vein), and numerous smaller
vessels which drain into the pharyngeal plexus.
The palatine tonsils receive innervation from the maxillary nerve and glossopharyngeal nerve.
Lymphatic Drainage
The palatine tonsils drain into the jugulodigastric and upper deep cervical lymph nodes.
Clinical Relevance: Tonsillitis

Tonsillitis refers to inflammation of the palatine tonsils. It is usually caused by viral infection, with bacterial
causes accounting for approximately 1/3 of cases.
Tonsillitis presents with difficult or painful swallowing – often with pyrexia and/or halitosis. On
examination, the tonsils appear erythematous and swollen with evidence of purulent exudate and
lymphadenopathy.
A complication of bacterial tonsillitis is a peritonsillar abscess (quinsy); a collection pus in the peritonsillar
space. All quinsies will require drainage. There are two techniques adopted for this:
 Needle aspiration following topical local anaesthetic.

 Incision and drainage, with further opening via use of Magill forceps.
Adapted from work by Adobe Stock (Licensed to TeachMeSeries Ltd) and James Heilman MD [CC BY-SA
3.0]
Fig 4 – Peritonsillar abscess, a collection of pus in the peritonsillar space as a complication of tonsillitis.

Anantomy of The Neck

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THE NECK

The Anterior Triangle of the Neck

 Superiorly – inferior border of the mandible (jawbone).

By TeachMeSeries Ltd (2023)

Fig 1 – Borders of the anterior triangle of the neck.

Suprahyoid Muscles Infrahyoid Muscles

By TeachMeSeries Ltd (2023)

The carotid triangle of the neck has the following boundaries:

 Superior – posterior belly of the digastric muscle.

By TeachMeSeries Ltd (2023)

Fig 3 – Carotid triangle of the neck

 Inferiorly – hyoid bone.

By TeachMeSeries Ltd (2023)

The boundaries of the submandibular triangle are:

 Superiorly – body of the mandible.

By TeachMeSeries Ltd (2023)

Fig 5 – Submandibular triangle of the neck

The boundaries of the muscular triangle are:

 Superiorly – hyoid bone.

By TeachMeSeries Ltd (2023)

Fig 6 – Muscular triangle of the neck.

II. The Posterior Triangle of the Neck

The Posterior Triangle of the Neck

 Anterior – posterior border of the sternocleidomastoid.

By TeachMeSeries Ltd (2023)

Clinical Relevance: The External Jugular Vein

By TeachMeSeries Ltd (2023)

Figure 2 – Nerves within the posterior triangle of the neck.

 Occipital triangle – located superior to the omohyoid.

2. Bones of the Neck

The Cervical Spine

 The first cervical vertebrae (C1) is known as the atlas.

BodyParts3D, The Database Center for Life Science.

Fig 1 – Overview of the location of the cervical spine.

 Triangular vertebral foramen.

By TeachMeSeries Ltd (2023)

Fig 2 – Characteristic features of a cervical vertebrae

By TeachMeSeries Ltd (2023)

Present throughout Vertebral Column

Unique to Cervical Spine

Present throughout Vertebral Column

 Ligamentum flavum – connects the laminae of adjacent vertebrae.

Unique to Cervical Spine

By TeachMeSeries Ltd (2023)

Fig 4 – Ligaments of the cervical spine.

By TeachMeSeries Ltd (2023)

Hyperextension (Whiplash) Injury

Fracture of the Dens

Fractures of the odontoid process represent ~40% of C2 fractures.

By James Heilman, MD [CC-BY-SA-3.0], via Wikimedia Commons

Fig 6 – A fracture of the base of the dens.

The Hyoid Bone

Adapted from work by OpenStax College [CC BY 3.0]

Fig 1 – Position of the hyoid bone in the neck.

By TeachMeSeries Ltd (2023)

Indeed, it acts as a site of attachment for many muscles in the neck:

Oral Cavity and Pharynx Suprahyoid Infrahyoid

Clinical Relevance: Fracture of the Hyoid Bone

3. Viscera of the Neck