THE HEAD AND NECK LECTURES

By
ANAS IBRAHIM YAHAYA
MBBS, M.Sc., ADCTA, PhD (London)
 What are the objectives of the
lecture today?

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The objectives are to know:
1. The topography of the face &
neck
2. The functions of those
structures in the face & neck
3. The clinical Anatomy of the
face & neck
Regions of the head and neck
Regions Lateral View Cont.
 Scalp
 Scalp consists of skin and subcutaneous
tissue which cover the skull.
 The scalp consists of 5 layers of tissue:
1. S = Skin
2. C = Connective Tissue
3. A = Aponeurosis
4. L = Loose connective tissue
5. P = Pericranium
Layers of Scalp
Muscle of scalp
Muscles of the Scalp
Occipito-frontalis
Muscles of the Scalp
Occipito-frontalis
Muscle of Facial Expression
Muscle of Facial Expression
Ear Muscles
Nose Muscles
Mouth
Buccinator
Buccinator
Buccinator
Buccinator
Motor to Face CN VII
 FACIAL INFECTION

 DANGEROUS AREA OF FACE

1. A triangular area bounded with an apex opposite
the medial angles of eyes & nose and a base
formed by the upper lip
2. It is drained by facial vein
3. It has important communications with cavernous
sinus:

supraorbital & superior ophthalmic veins

Facial vein Cavernous sinus

deep facial vein pterygoid plexus of veins emmissary veins

 FACIAL INFECTION

 DANGEROUS AREA OF FACE

 Infection of this area may lead to:
1. Thrombosis of facial vein
2. Infection may be transmitted to
cavernous sinus leading to cavernous
sinus thrombosis
 TRIGEMINAL NERVE

 Supplies the skin of the face EXCEPT

the area over the angle of mandible &
parotid gland
 Is represented by 3 divisions:
1. Ophthalmic
2. Maxillary
3. Mandibular
TRIGEMINAL NERVE
 TRIGEMINAL NERVE
 OPHTHALMIC:
1. Supratrochlear:
forehead + medial part
of upper eyelid
2. Supraorbital: same
3. Palpebral branch of
lacrimal: lateral part of
upper eyelid
4. Infratrochlear: upper
part of nose
5. External nasal: lower
part of nose
 TRIGEMINAL NERVE
 MAXILLARY:
1. Infraorbital: divides
into: a) palpebral
for lower eyelid,
b) nasal for ala of
nose, c) labial for
upper lip
2. Zygomaticofacial:
upper part of cheek
 TRIGEMINAL NERVE
 MANDIBULAR:
1. Buccal: lower part
of cheek
2. Mental: lower lip &
chin
 TRIGEMINAL NEURALGIA

 Inflammatory condition affecting one or

more of the three divisions of trigeminal
nerve
 Gives rise to severe pain in the area of
distribution of the affected nerve
 Surgical treatment may involve:
1. Alcohol injection of the trigeminal ganglion
2. Section of the central root of the nerve or of
the appropriate division
FACIAL NERVE
 FACIAL NERVE
 Extracranial course:
1. The nerve leaves the cranial cavity through stylomastoid
foramen
2. The nerve enters the parotid gland & divides into 5 terminal
motor branches that emerge from the gland
 Extracranial distribution:
 After emergence from stylomastoid foramen:
1. Posterior auricular: to occipital belly of occipitofrontalis muscle
2. Muscular branch to posterior belly of digastric
3. Muscular branch to stylohyoid
 After emergence from parotid gland:
1. Temporal: to orbicularis oculi, frontal belly of occipitofrontalis
muscles
2. Zygomatic: to orbicularis oculi muscle
3. Buccal: to buccinator, muscles of upper lip & nose
4. Mandibular: to muscles of lower lip
5. Cervical: to platysma
 FACIAL NERVE INJURY

 UPPER MOTOR NEURONE LESION

(SUPRANUCLEAR LESION): e.g. lesion in
pyramidal tracts: paralysis of muscles on the
lower quadrant of face opposite to the side of
lesion (the patient can close his eye but
cannot expose his teeth on the affected side)
 LOWER MOTOR NEURONE LESION
(NUCLEAR OR INFRANUCLEAR LESION):
e.g. Bell’s palsy: paralysis of all muscles of
face on same side of lesion (the patient
cannot close his eye and cannot expose his
teeth on the affected side)
ARTERIES OF FACE
 FACIAL ARTERY

 ORIGIN: A branch of external carotid in the neck

 COURSE IN FACE:
1. Curves around the lower border of mandible (pulse
can be felt)
2. Ascends: lateral to lips & nose, anterior to
facial vein
3. Runs a tortuous course
 TERMINATION: at the medial angle of eye, where it
anastomoses with branches of ophthalmic artery
 BRANCHES IN FACE:
1. Inferior labial
2. Superior labial
3. Lateral nasal
SUPERFICIAL TEMPORAL ARTERY

 ORIGIN: One of the 2 terminal branches of

external carotid artery in the parotid gland
 COURSE:
1. Ascends in front of auricle (pulse can be felt)
2. Accompanies the auriculotemporal nerve
 BRANCHES:
1. Transverse facial: arises inside the parotid
gland & runs transversally above parotid
duct
2. anterior & posterior branches: supply the
scalp
 Structures in the neck:

Larynx
Pharynx
Oesophagus
Trachea
Thyroid gland/parathyroid glands
Muscles
Fasciae
NVB

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 Bones of the Neck Region
 The Cervical Vertebrae
 Small body (support only head)
 Large vertebral foramen (largest part of spinal cord)
 Concave superior surface
 Slopes posterior to anterior
 C1 (atlas) has no spinous process
 All others have short spinous processes
 tip of each spinous process
is notched (bifid)
 Vertebral Regions

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  Transverse processes
 Are fused to costal processes
 Which encircle transverse foramina
(protect arteries and veins)
 Atlas (C1)
 Articulates with occipital condyles
 Has no body or spinous process
 Has a large, round foramen
 Axis (C2)
 Supports the atlas
 Has heavy spinous process
 To attach muscles of head and neck
 Dens = fused bodies of c1 & c2
 Vertebra prominens (C7)
 Has a long spinous process with a broad tubercle
 Has large transverse processes
 Ligamentum nuchae (elastic ligament) extends from C7 to skull

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Vertebral Regions
 Inter-vertebral disc:
B/w vertebral bones
Secondary cartilaginous joints
2 parts = annulus, nucleus pulposus
Herniation

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 Ligaments of the cervical
vertebrate

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Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings
Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings
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Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings
Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings
 The pharyngo-esophageal
junction appears as a
constriction produced by the
cricopharyngeal part of the
inferior pharyngeal
constrictor muscle (the
superior esophageal
sphincter) and is the
narrowest part of the
esophagus.
 Gross anatomy of Pharynx

 The pharynx is the continuation of the digestive system

from the oral cavity
 It is a funnel-shaped fibromuscular tube that serve as
common route for both food and air
 The phraynx extends from cranial base to the inferior
boarder of the of the cricoid cartilage at level of C6
 The pharynx is located posterior to the nasal and oral
cavities and the larynx
 It is widest above (5cm) and narrowest (1.5cm) at its
inferior where it is continious with esophagus
 Pharyngeal wall

 Mucosal layer
 Submucosa
 Pharyngobasilar fascia
 Pharyngeal Muscle layer
 Buccopharyngeal fascia
 Mucosal layer
 Nasopharynx – Ciliated columnar epithelium
 Oropharynx – Stratified squamous epithelium
 Laryngopharynx - Stratified squamous epithelium
 Submucous layer
Fibrous layer
Thick in the upper part where the
muscular layer is deficient
 Muscular Layer

 Consist of circular muscles

Superior, Middle and Inferior constrictor muscle
 Of the three pharyngeal constrictor muscles, the inferior muscle
overlaps the middle one and the middle one overlaps the
superior one, All three muscles form a common median
pharyngeal raphe posteriorly
 Longitudinal muscles
Palatopharyngeus
Stylopharyngeus
Salpingopharyngues
 Function of the muscles

 External circular muscles: Constrict walls

of pharynx during swallowing
 Internal longitudinal muscles: Elevate
(shorten and widen) the pharynx during
swallowing
 ESOPHAGUS
 Muscular tube, length at birth = 10cm, in adult = 25 cm
 Diameter = varies on food item swallowed, at rest = 2cm
 Collapsed at rest (flat in upper 2/3) & rounded in lower 1/3
 Begins at C6, but in newborn = C4 or C5
 Has 2-3 slight curvatures (within the thorax only)
 At C6 & root of the neck (midline)
 Oesophagus has three constrictions:
 15 cm from incisor teeth is crico-
pharyngeus sphincter
 25 cm from incisor teeth = aortic arch
and left main bronchus indent it
 40 cm from incisor teeth = it pierces the
diaphragm and therefore narrow here
 Esophagus relations in the neck

 Trachea = anteriorly
 Posteriorly = vertebral column and
Longus coli muscle
 Laterally = common carotid artery,
part of the lateral lobes of the thyroid
gland; the recurrent laryngeal nerves
 Site of impaction =
constriction areas
1.Cricopharyngeus
2.Others in the thorax

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 Esophagus at the thoracic inlet
= most common site of oesophageal
impaction
= the site of anatomical change from the
skeletal muscle to the smooth muscle
=The cricopharyngeus slings at C6 and
foreign body can lodge here
Histological features of Esophagus

1. Mucosa (3 layers): 2. Submucosa: loose

I. Epithelium = stratified areolar tissue
sqamous non-
keratinized contains;Serous and
II. Lamina propria: fibrous mucous glands, Blood
tissue, lymphocytes
III. Muscularis mucosae:
vessels, Lymphatic
channels, Meissner's
3. Muscularis externa: nerve plexus
-Outer longitudinal muscle 4. Adventitia: Layer of
-Inner circular muscle loose supportive fibrous
Auerbach's nerve tissue, Conducts major
plexus lies b/w them vessels & nerves
 Larynx
 The larynx consists of 4 main structures:

- A cartilaginous skeleton
- Membranes and ligaments
- Intrinsic and extrinsic muscles
- Mucosal lining
 The Cartilages
• The cartilaginous skeleton are:

 Un-paired Cartilages:
 Thyroid
 Cricoid
 Epiglottis
 Paired Cartilages:
 Arytenoid
 Corniculate
 Cuneiform
 All the cartilages, except the epiglottis,
are of hyaline type.
 Epiglottis is formed of elastic cartilage
 The cartilages are:
 Connected by joints, membranes &
ligaments
 Moved by muscles
 Thyroid Cartilage
 Has 2 laminae, meet in the midline and
form a prominent angle, called
laryngeal prominence (Adam’s apple)
 Has thyroid notch
 Posterior border of each lamina =
superior & inferior cornu (horns)
 Outer surface of each lamina = oblique
superior
line for attachment to 3 muscles cornu
Oblique
-thyrohyoid line

-sternothyroid
-inferior constrictor of the pharynx
 The superior border gives attachment
to the thyrohyoid membrane
inferior
cornu
 Cricoid Cartilage
 Is a complete ring below the
thyroid cartilage
 Has narrow anterior arch & a
broad posterior lamina
 Has an articular facet on its:
• Lateral surface for articulation
with inferior cornu of the
thyroid cartilage (a synovial
joint)
• Upper border for articulation
with base of arytenoid
cartilage (a synovial joint)
 Arytenoid Cartilages
 Small, pyramidal cartilage
 Base articulates with the upper
border of the cricoid cartilage
• Apex supports the corniculate
cartilage
• It has 2 processes: vocal
process projects forward, & gives
attachement to the vocal ligament
• A muscular process projects
laterally, & gives attachment to
muscles
 Un-paired Cartilages
Corniculate Cartilages
 Small nodules
 Articulate with the apices of arytenoid E
cartilages
Cuneiform Cartilages
V
 Small rod shaped, placed in each CU F
aryepiglottic fold, producing a small
CO
elevation
 Do not articulate with any other cartilage
but serve as support for the ary-epiglottic fold
 Epiglottis
 Leaf shaped, situated behind the root of the
tongue
 Connected:
 In front to the body of hyoid bone by the
hyoepiglottic ligament
 By its stalk to the back of thyroid cartilage
by the thyroepiglottic ligament
 Upper edge is free.
 Laterally gives attachment to aryepiglottic fold
 Anteriorly mucosa is reflected onto the tongue
forming three glossoepiglottic folds &
valleculae
 Membranes & Ligaments
 Thyrohyoid membrane, thickens to form:
median & lateral thyrohoid ligaments
 Median cricothyroid ligament
 Cricotracheal membrane
 Hyoepiglottic ligament
 Thyroepiglottic ligament
 Quadrangular membrane:
 Extends between the epiglottis and
the arytenoid cartilages
 Its lower free margin forms the
vestibular ligament that lies within
the vestibular fold
 Cricothyroid membrane (conus
elasticus):
 Lower margin is attached to upper
border of cricoid cartilage
 Upper free margin forms vocal
ligament that is attached anteriorly to
deep surface of thyroid cartilage &
posteriorly to the vocal process of
arytenoid cartilage
 Laryngeal Inlet
 Faces backward and upward and
opens into the laryngeal part of the
pharynx
 The opening is bounded:
• Anteriorly: by the upper margin of
epiglottis
• Posteriorly & below by arytenoid
cartilages
• Laterally by aryepiglottic folds

CU

CO
AEF
A
 Laryngeal Cavity
 Extends from laryngeal
inlet to lower border of
the cricoid cartilage
 Narrow in the region of Rima
vestibu
the vestibular folds (rima li

vestibuli)
 Narrowest in the region
of the vocal folds (rima
glottidis)
Rima
glottidi
s
 Laryngeal Cavity cont’d
 Divided into 3 parts:
1. Supra-epiglottic
part, the part above
the vestibular folds,
is called the
vestibule
2. The part between
A
the vestibular & the
vocal folds, is B
called the ventricle
C
3. Infra-epiglottic part,
the part below the
vocal folds
 Vestibular Part:
 Extends from the inlet to the vestibular
fold
 Below it becomes narrow as the
vestibular folds project medially.
 Each vestibular fold contains
vestibular ligament, the lower free
margin of the quadrangular membrane
stretching from thyroid cartilage to the
arytenoid cartilage
 Lower Part:
 Extends from vocal folds to lower
border of cricoid cartilage
 Walls formed by the inner surface of
the cricothyroid ligament and the
cricoid cartilage
 Mucous Membrane
 The cavity = lined with ciliated columnar epithelium
 The surface of vocal folds, because it is exposed to continuous trauma during
phonation, is covered by stratified squamous epithelium
 Contains many mucous glands, more numerous in the saccule (for lubrication of
vocal folds)
 LARYNGEAL MUSCLES (2 GROUPS)
:
 Extrinsic muscles (2 groups):
• Elevators of the larynx
• Depressors of the larynx
 Intrinsic muscles (2 groups):
• Muscles controlling the laryngeal inlet
• Muscles controlling the movements of the vocal cords
 EXTRINSIC MUSCLES

ELEVATORS
 The Suprahyoid Muscles
 Digastric
 Stylohyoid
 Mylohyoid
 Geniohyoid
 The Longitudinal Muscles of the
Pharynx
 Stylopharyngeus
 Salpingopharyngeus
 Palatopharyngeus

DEPRESSORS
 The Infrahyoid Muscles
 Sternohyoid
 Sternothyroid
 Omohyoid
 Muscles Controlling the Laryngeal Inlet

 Oblique arytenoid
 Aryepiglottic muscle
 Movements of the Vocal Cords

 Adduction
 Abduction

Glottis (space between

Folds closed (adducted) Folds open folds)
(abducted) (View from above)
 Adductors of the Vocal Cords
 Lateral cricoarytenoid
 Transverse arytenoid
 Abductor of the Vocal Cords

 Posterior cricoarytenoid
THYROID AND PARATHYROID
GLANDS
 INTRODUCTION

 The thyroid gland = the largest endocrine

gland; it has a weight of 20 to 25 g
 It receives one of the body’s highest rates of
blood flow per gram of tissue
 Thyroid gland

Isthmus

Trachea
EMBRYOLOGY OF THYROID GLAND
 Floor of the pharynx
 Tuberculum impar and the copula
 Foramen cecum
 Thyroid descends in front of the pharynx
as a bilobed diverticulum
 Connected to tongue by thyroglossal
ducts
 This duct later disappears.
 Descends in front of the hyoid bone and
the laryngeal cartilages
 It reaches its final position in front of the
trachea in the 7th week of IUTL

 Functions end of 3rd month, at which time

the first follicles containing colloid
become visible
 EMBRYOLOGY OF PARATHYROID
GLANDS

 Inferior parathyroid glands = parathyroid

III , = proliferation of endodermal cells in the
3rd pharyngeal pouch on each side.
 As the thymic diverticulum on each side
grows inferiorly in the neck, it pulls the inferior
parathyroid with it, so that it finally comes to
rest on the posterior surface of the lateral
lobe of the thyroid gland near its lower pole
and becomes completely separated from the
thymus
 Superior parathyroid glands =
parathyroid IV , = proliferation of
endodermal cells in the 4th pharyngeal
pouch on each side.
 These loses their connection with the
pharyngeal wall and take up their final
position on the posterior aspect of the
lateral lobe of the thyroid gland on each
sides.
GROSS ANATOMY OF THYROID GLAND

 Parts: two lobes , isthmus.

Sometimes there is pyramidal
lobe on the upper border
of the isthmus.
 Pyramidal lobe may be
connected to the hyoid bone
by a band of connective tissue
(remnant of thyroglossal duct).
RELATIONS OF THE THYROID GLAND

 Each lobe is pyramidal

In shape, has an apex, base
and three surfaces.
 Apex- extends up to the
oblique line of thyroid
cartilage.
 Base- is at the level of 5th
tracheal ring.
 Lateral surface-
covered by infrahyoid
and sternocleidomastoid
muscle.
 Posterior surface –
related to carotid sheath
and contents.
 Medial surface –
is related to trachea,
esophagus, cricoid
and thyroid cartilages,
recurrent and external
laryngeal nerves.
ISTHMUS OF THE THYROID GLAND

Connects two lobes.

Lies in front of the 2nd, 3rd tracheal rings
(sometimes 4th).

Covered by infrahyoid muscles.

Inferior thyroid vein emerges from its lower

border.
 BLOOD SUPPLY

ARTERIAL SUPPLY :
Superior thyroid artery, a
branch of external
carotid artery.

Inferior thyroid artery –

branch of thyrocervical
artery (branch of subclavian
artery).

 Thyroidea ima from

arch of aorta( occasional).
 VENOUS DRAINAGE

 Superior thyroid vein –

drains into internal
jugular vein.
 Middle thyroid vein –
drains into internal
jugular veins.
 Inferior thyroid vein –
drains into the left
brachiocephalic vein
in the thorax.
 Last two veins are not
accompanied by
arteries
 LYMPHATIC DRAINAGE
Prelaryngeal
Pretracheal
Paratracheal nodes.

Some accompany
superior thyroid vein
to end in the lower
deep cervical nodes.
 Nerve supply;
Is by superior, middle and inferior cervical
sympathetic ganglia.
 PARATHYROID GLANDS

Ovoid bodies measuring about 6mm long in

their greatest diameter.
They are four in number and are
closely related to the posterior border of
the
thyroid gland, lying within its fascial
capsule
 The two superior parathyroid glands
are more constant in position and lie at
the level of the middle of the posterior
border of
the thyroid gland.
 The two inferior parathyroid glands
usually lie close to the inferior poles of the
thyroid gland.

 They may lie within the fascial sheath,

embedded in the thyroid substance, or
outside the fascial sheath.
 Blood Supply:
The arterial supply
It’s from the superior and inferior thyroid
arteries.
The venous drainage
It’s into the superior, middle, and inferior
thyroid veins.
Lymph Drainage:
Is by Deep cervical and paratracheal lymph
nodes
 Nerve Supply:
Is by superior or middle cervical
sympathetic ganglia.
 MICROSCOPIC STRUCTURE OF
THYROID GLAND

 The thyroid gland is covered by fibrous

capsule
 The septum extending into the glands
from the capsule divide it into a number
of lobules
 Each lobule is made up of aggregation
of follicles
 Each follicles is lined by follicular cells
 They rest on the basement membrane
 The follicles have a cavity filled with
homogeneous material called colloid
 The space between the follicles are filled
by stroma made up of delicate connective
tissue containing numerous capillaries and
lymphatics.
 The capillaries are in close contact with
the walls of the follicles
 The parafollicular cells are larger than the
follicular cells
 They intervene between the follicular cells
and the basement membrane
 They also lie between the follicles.
 They secrete calcitonin which regulates
the level of calcium in the blood.
 HISTOLOGY OF
PARATHYROIDS
 Each gland has a connective
tissue capsule from which septal
extends into the gland substance
 The cells of parathyroid glands
are of two types
 Chief cells (principal cells)
 Oxyphils cells or Eosinophils
cells.
 CLINICAL ANATOMY OF THYROID
GLAND

 A thyroglossal cyst may lie at any

point along the migratory pathway of
the thyroid gland but is always near or
in the midline of the neck. As
indicated by its name, it is a cystic
remnant of the thyroglossal duct.
Thyroglossal cyst
LINGUAL THYROID
Thyroglossal duct sinus
 Swelling of Thyroid Glands (Goiter):
 Absence and Hypoplasia of the
Parathyroid
Glands

Agenesis or incomplete development of the

parathyroid glands has been demonstrated
in an individuals with idiopathic
hypoparathyroidism.
 Ectopic Parathyroid Glands:
The close relationship between the parathyroid III
and the developing thymus explains the frequent
finding of parathyroid tissue in the superior
mediastinum of the thorax.
If the parathyroid glands remain attached to
the thymus, they may be pulled inferiorly into the
lower part of the neck or thoracic cavity.
Moreover, this also explains the variable position of
the inferior parathyroid glands in relation to the
lower poles of the lateral lobes of the thyroid gland.
ECTOPIC TISSUE
Ectopic thyroid tissue
 Extra thyroid tissue may
be present anywhere
along the migratory path of thyroglossal
duct.
Blood Supply of
Head & Neck
 Objectives
• Enlist the major arteries supplying head and neck.
• How common carotid arteries take origin.
• Enlist important relations of common carotid arteries.
• Describe the relations and branches of external carotid
artery.
• Describe the relations and branches of subclavian
artery.
• Enlist the major veins supplying head and neck.
• Discuss the formation of external and internal jugular
veins.
• Describe the tributaries of external and internal jugular
veins.
 Arteries of Head & Neck

• Common Carotid Artery

• External Carotid Artery

• Internal Carotid Artery

• Subclavian Artery
 Common Carotid Arteries
Right Common Carotid Artery:
 Arises from brachiocephalic artery
(Behind right sternoclavicular joint)
Left Common Carotid Artery:
 Arises from Arch of Aorta
 Runs upwards in the neck from sternoclavicular
joint to upper border of thyroid cartilage
Common Carotid Arteries
Common Carotid Arteries
Relations of Common Carotid Artery
Anterolaterally:
 Sternocleidomastoid
 Sternohyoid
 Sternothyroid
 Superior belly of omohyoid
Posteriorly:
 Prevertebral muscles
Medially:
 Larynx
 Pharynx
Laterally:
 Internal jugular vein
 Branches of Common Carotid Artery

 External Carotid Artery

 Internal Carotid Artery

Common Carotid Arteries
 External Carotid Artery
 Begins at the level of upper border of thyroid cartilage
 Terminates in the substance of the parotid gland behind
the neck of mandible by dividing into:
 Superficial temporal artery
 Maxillary artery
Supply of External Carotid Artery
 Neck
 Face
 Scalp
 Tongue
 Maxilla
Branches of External Carotid Artery
 Superior thyroid artery
 Ascending pharyngeal artery
 Lingual artery
 Facial artery
 Occipital artery
 Posterior auricular artery
 Superficial temporal artery
 Maxillary artery
Branches of External Carotid Artery
Branches of External Carotid Artery
 Internal Carotid Artery

 Begins at the level of upper border of thyroid

cartilage
 No branches in the neck
 Through carotid canal enters into cranial cavity
 Supplies brain, eyes, forehead and part of the nose
 Subclavian Artery
Right Subclavian Artery:
 Arises from brachiocephalic artery
(Behind right sternoclavicular joint)
 At outer border of 1st rib it becomes Axillary Artery
Left Subclavian Artery:
 Arsis from Arch of Aorta in the thorax
 Runs upwards to the root of the neck & arches
laterally
 At outer border of 1st rib it becomes Axillary Artery
 Subclavian Artery
Scalenus Anterior muscle passes anterior to the
artery on each side and divides it into 3 parts.

1. 1st part of subclavian artery

2. 2nd part of subclavian artery

3. 3rd part of subclavian artery

 1 part of Subclavian Artery
st

Extends from the origin of the subclavian artery to

the medial border of the Scalenus anterior muscle.
Branches:

1. Vertebral artery

2. Thyrocervical Trunk

3. Internal thoracic artery

 1 part of Subclavian Artery
st

Branches:

1. Vertebral artery
 Spinal and muscular branches in neck
 Branches in skull
 1 part of Subclavian Artery
st

Branches:

2. Thyrocervical Trunk
 Inferior thyroid artery
 Superficial cervical artery
 Suprascapular artery
 1 part of Subclavian Artery
st

Branches:

3. Internal thoracic artery

 Superior epigastric artery
 Musculophrenic artery
 2 part of Subclavian Artery
nd

Lies behind the Scalenus anterior muscle.

Branches:

1. Costocervical trunk

 Superior intercostal artery

 Deep cervical artery
 3 part of Subclavian Artery
rd

Extends from the lateral border of the Scalenus

anterior muscle to the lateral border of 1 st rib.
Branches: (Occasional)

1. Superficial cervical artery

2. Suprascapular artery
Subclavian Artery
Branches of Subclavian Artery
 Veins of Head & Neck

• Veins of Brain

• Venous Sinuses

• Veins of Face and Neck

 Veins of Face and Neck
 Facial vein
 Superficial temporal vein
 Maxillary vein
 Retromandibular vein
 External jugular vein
 Anterior jugular vein
 Internal jugular vein
 Subclavian vein
Veins supplying Head and Neck
 Facial Vein
Formed at medial
angle of eye by
the union of
supraorbital and
supratrochlear veins.
It joins anterior
division of
retromandibular vein
 Superficial temporal Vein
Formed on the side of the scalp. Enters parotid gland.
It joins maxillary vein to form Retromandibular vein.
 Maxillary Vein
Formed in the Infratemporal fossa from the Pterygoid venous plexus.
It joins superficial temporal vein to form Retromandibular vein.
 Retromandibular Vein
 Formed by the union of maxillary vein and superficial
temporal vein.
 Leaving parotid gland divides into anterior branch and
posterior branch.
 Anterior branch joins facial vein.
 Posterior branch joins posterior auricular vein to form
external jugular vein.
 External jugular Vein
 Formed behind the angle of jaw by the union of
Posterior branch of retromandibular vein with
posterior auricular vein.
 It drains into subclavian vein
 Tributaries:
 Posterior external jugular
 Transverse cervical
 Suprascapular
 Anterior jugular
 Internal jugular Vein
 Receives blood from brain, face and neck.
 Continuation of sigmoid sinus and leave the skull from
jugular foramen.
 Ends by joining subclavian vein to form brachiocephalic
vein.
 Tributaries:
 Facial vein
 Pharyngeal vein
 Lingual vein
 Superior thyroid vein
 Middle thyroid vein
 Subclavian Vein

 Continuation of axillary vein at the outer border of 1st rib.

 Joins internal jugular vein to form brachiocephalic vein.
Tributaries:
 External jugular vein
Brachiocephalic Veins & SVC
SCALENE & PREVERTEBRAL
MUSCLES
CERVICAL PLEXUS
 Scalenus Anterior Muscle

 The scalenus anterior muscle is a key

muscle in understanding the root of the
neck

 It is deeply placed

 It descends almost vertically from the

vertebral column to the first rib
 Anterior Relation

 Related to the carotid arteries, the vagus

nerve, the internal jugular vein, and the
deep cervical lymph nodes

 The transverse cervical and suprascapular

arteries and the prevertebral layer of deep
cervical fascia bind the phrenic nerve to
the muscle
 Posterior Relation

 Related to the pleura, the origin of the

brachial plexus, and the second part of the
subclavian artery

 The scalenus medius muscle lies behind

the scalenus anterior muscle
 Medially

 Related to the vertebral artery and vein

and the sympathetic trunk

 On the left side, the medial border is

related to the thoracic duct
 Laterally

 Related to the emerging branches of the

cervical plexus, the roots of the brachial
plexus, and the third part of the subclavian
artery
 Scalenus Anterior Muscle

Origin:
 Transverse processes of third, fourth, fifth, and
sixth cervical vertebrae

Insertion:
 First rib

Action:
 Elevates first rib, laterally flexes and rotates
cervical part of vertebral column
 Scalenus Medius

 It lies behind the scalenus anterior

 It extends from the transverse process of the atlas and

the transverse processes of the next five cervical
vertebrae

 Inserted into the upper surface of the first rib behind the
groove for the subclavian artery

 The muscle lies behind the roots of the brachial plexus

and the subclavian artery
 Scalenus Posterior

Origin:
 Transverse processes of lower cervical
vertebrae

Insertion:
 Second rib

Action:
 Elevates second rib, laterally flexes and
rotates cervical part of vertebral column
 Longus Colli Muscle

Origin:
 Anterior tubercle of C1, bodies of C1 to C3 and
transverse processes of C3 to C6 vertebrae

Insertion:
 Bodies of C5 to T3 vertebrae, transverse
processes of C3 to C5 vertebrae

Action:
 Flexes neck with rotation to opposite side
 Longus Capitis Muscle

Origin:
 Basilar part of occipital bone

Insertion:
 Anterior tubercles of C3 to C6 transverse
processes

Action:
 Flexes the head
 Rectus Capitis Anterior

Origin:
 Base of the skull, just anterior to the occipital
condyle

Insertion:
 Anterior surface of lateral mass of atlas

Action:
 Flexes the head
 Rectus Capitis Lateralis

Origin:
 Jugular process of occipital bone

Insertion:
 Transverse process of atlas

Action:
 Flexes head and helps stabilize it
 Splenius Capitis

Origin:
 Inferior half of nuchal ligament and spinous processes of
superior 6 thoracic vertebrae

Insertion:
 Lateral aspect of mastoid process and lateral third of
superior nuchal line

Action:
 Laterally flexes and rotates head and neck to same side,
extend head and neck
 Cervical Plexus

 The cervical plexus is formed by the

anterior rami of the first four cervical
nerves

 The rami are joined by connecting

branches, which form loops that lie in front
of the origins of the levator scapulae and
the scalenus medius muscles
 Cervical Plexus

 The plexus is covered in front by the

prevertebral layer of deep cervical fascia

 Is related to the internal jugular vein within the

carotid sheath

 The cervical plexus supplies the skin and the

muscles of the head, the neck, and the
shoulders
 Cutaneous Branches

The lesser occipital nerve (C2):

 Supplies the back of the scalp and the auricle

The greater auricular nerve (C2 and3):

 Supplies the skin over the angle of the mandible

The transverse cervical nerve (C2 and 3):

 Supplies the skin over the front of the neck
 Cutaneous Branches

The supraclavicular nerves (C3 and 4)

 The medial, and intermediate, and lateral
branches supply the skin over the
shoulder region
 These nerves are important clinically,
because pain may be referred along them
from the phrenic nerve (gallbladder
disease)
 Muscular Branches

 Prevertebral muscles, sternocleidomastoid (proprioceptive, C2 and

3), levator scapulae (C3 and 4), and trapezius (proprioceptive, C3
and 4)
 A branch from C1 joins the hypoglossal nerve
 Some of these C1 fibers later leave the hypoglossal as the
descending branch, which unites with the descending cervical nerve
(C2 and 3), to form the ansa cervicalis
 Muscular Branches

 The first, second, and third cervical nerve

fibers within the ansa cervicalis supply the
omohyoid, sternohyoid, and sternothyroid
muscles

 Other C1 fibers within the hypoglossal

nerve leave it as the nerve to the
thyrohyoid and geniohyoid
 Phrenic Nerve

 It arises in the neck from the third, fourth, and

fifth cervical nerves of the cervical plexus

 It runs vertically downward across the front of

the scalenus anterior muscle

 Enters the thorax by passing in front of the

subclavian artery
 Phrenic Nerve

 The phrenic nerve is the only motor nerve

supply to the diaphragm

 It also sends sensory branches to the

pericardium, the mediastinal parietal
pleura, and the pleura and peritoneum
covering the upper and lower surfaces of
the central part of the diaphragm
MUSCLES AND TRIANGLES OF THE
NECK
 The anterolateral part of the neck is
quadrilateral area which is divided by
sternomastoid muscle into 2 large
triangular areas ( anterior and posterior ) .
 The investing layer of deep fascia roofs
both triangles .
• Sternomastoid muscle :
• 1- action :when one muscle acts alone , it bends
the head to its same side and rotates it to the
opposite side ( the face looks to the opposite
side
• As you want to approximate the mastoid process
to the manubrium of the sternum ).
• When the two muscles act together , they flex the
head .
• 2-Nerve supply : 1- the spinal root of the
accessory nerve (motor )
• 2- the cervical nerves C2&C3 (proprioceptive )
Omohyoid
Sternomastoid
muscle
muscle
 Relations of the sternomastoid

 1- superficial relations :
 1- the lower end of the parotid gland .
 2- the great auricular nerve .
 3- anterior cutaneous nerve of the neck .
 4- external jugular vein .
 Parotid
gland

Great
auricular
nerve

Transverse
cutaneous nerve of
the neck

External
jugular vein
• Deep relations :
• A- Deep relations to its upper half :
• 1- posterior belly of digastric muscle .
• 2- spinal accessory nerve .
• 3- splenius capitis
• 4- occipital artery
• B- Deep relations to its lower half :
• 1- intermediate tendon of omohyoid muscle .
• 2- transverse cervical artery .
• 3- suprascapular artery
• 4- anterior jugular vein
• 5- scalenous anterior
• 6- phrenic nerve
• 7- carotid sheath and its contents
• Stucture emerging from its posterior
border (they appear in the posterior
triangle )
• 1- branches of the cervical plexus
• 2- trunks of brachial plexus
• 3- spinal accessory nerve
• 4- transverse cervical artery &suprascapular
arteries
• 5- the 3rd part of subclavian artery
• 6- deep cervical lymph nodes
 Clinical importance of the sternomastoid
muscle :
 1- congenital torticollis : (wry neck ), it is a
fibrous tissue tumour or injuiry of the
muscle during birth .
 2- spasmodic torticollis : abnormal tonicity
in the muscle .
 apex

trapezius
muscle

Investing
Sternomastoid
layer of
muscle
deep fascia
roof

Middle
1/3 of
clavicle –
base
 The posterior triangle

• the posterior triangle lies behind the sternomastoid

muscle , it has an apex , base and 2 borders .
• The outlines of the posterior triangle :
• 1- the posterior border of the sternomastoid
muscle . (infront )
• 2- the anterior border of trapezius muscle(behind )
• 3- the middle one third of the clavicle forms the
base of the triangle .
• 4- the meeting of the sternomastoid muscle and
trapezius muscle forms the apex of the triangle .
• Roof :
• It consists of the following layers (from outwards
inwards )
• 1-the skin
• 2- the superficial fascia containing :
• 1- the platysma muscle (very thin sheet of muscle
layer )
• 2- the external jugular vein
• 3- the deep fascia of the roof ( part of the general
investing layerof the deep fascia of the neck ) .
• Floor :
• The deep fascia of the floor ( prevertebral
fascia ) which cover the muscles of the floor .
• The muscles of the floor ( arranged from
below upwards )
• 1- scalenus medius
• 2- levator scapulae
• 3- splenius capitis
• 4- semi- spinalis capitis ( at the apex of the
triangle )
 The posterior triangle is subdivided by the
inferior belly of omohyoid into 2 smaller
triangles :
 1- the occipital triangle ( above )
 2- the subclavian triangle ( below )
Contents of the posterior triangle

 1- nerves, remember that the main

contents of the posterior triangle are
nerves .
 2- vessels ( arteries and veins )
 3- the inferior belly of the omohyoid
muscle
Spinal
part of
accessory
nerve
• Cervical plexus :
• It is formed by the anterior rami of the upper
4 cervical nerves .
• It gives off 4 muscular branches :
• 1- nerve to sternomastoid muscle ( C2&C3
proprioceptive)
• 2- nerve to trapezius muscle ( C3&C4
proprioceptive)
• 3- nerve to levator scapulae muscle ( C3&C4)
• 4- roots to the phrenic nerve . (C3&C4 & C5)
 Cutaneous branches of the cervical plexus
:
 1- lesser occipital nerve (C2)
 2- great auricular nerve (C2&C3).
 3- transverse cervical nerve (C2&C3)
 4- supraclavicular nerves (C3&C4)
 Arteries :
 1- 3rd part of subclavian artery .
 2- two branches which come from the 1 st part of
the subclavian artery ( transverse cervical artery
and suprascapular artery )
 Veins :
 1- subclavian vein
 2- transverse cervical vein
 3- suprascapular vein
 The anterior triangle of the neck

• It lies in front of the sternomastoid muscle .

• It is bounded by :
• 1- anterior border of sternomastoid muscle .
(behind)
• 2- anterior midline of the neck ( in front )
• 3- lower border of the mandible (base )
• It is subdivided into 4 triangles by means of
the superior belly of omohyoid muscle , the
anterior and posterior bellies of digastric
muscle as follows :
 1- Digastric triangle
 2- carotid triangle
 3- Muscular triangle
 4- Submental triangle
Posterior
belly of
digastric

Stylohyoid Anterior belly of

digastric muscle

Sternohyoid
muscle
 Digastric triangle

• Outlines :
• Above : the lower border of the mandible
• Below & infront : the anterior belly of Digastric
muscle
• Below & behind : the posterior belly of
Digastric and stylohyoid muscles .
• Floor :
• Anteriorly : the mylohyoid muscle
• Posteriorly : part of hyoglossus muscle
 Contents of the Digastric triangle

• 1- submandibular salivary gland

• 2- the submandibular lymph nodes lie on
the surface of the gland
• 3- facial artery deep to posterior end of
submandibular salivary gland
• 4- facial vein lies superficial to
submandibular salivary gland
• 5- hypoglossal nerve
• 6- nerve to mylohyoid muscle
Anterior belly
d
of digastric
Digastric triangle

Posterior
belly of
digastric
Carotid triangle

Mylohyoid
muscle
forms the Muscular triangle
floor of
the mouth
 Carotid triangle

• Outlines :
• Behind : the sternomastoid muscle
• Infront and above : the posterior belly of digastric
muscle
• Infront and below : the superior belly of omohyoid
muscle
• Floor : infont : the hyoglossus muscle ( above )
and the thyrohyoid muscle (below)
• Behind: the middle constrictor muscle of the
pharynx (above ) and the inferior constrictor
muscle of the pharynx (below )
Internal
carotid
artery

External carotid
artery

Common carotid
artery
 Contents of the Carotid triangle

 1- The carotid sheath and its contents :

 - common carotid artery : in the lower part
of the triangle .
 - internal carotid artery : in the upper part
of the triangle .
 Internal jugular vein : lateral
 Vagus nerve : between the artery and the
vein but in a more posterior plane .
 2- the external carotid artery : gives most of its
branches in the carotid triangle ( superior thyroid
artery ,lingual artery ,facial artery , ascending
pharyngeal artery and occipital artery )
 3- hypoglossal nerve
 4- Descendes cervicalis (C2,3) anterior to
carotid sheath.
 5- sympathetic trunk adherent to the posterior
wall of carotid sheath
 Muscular triangle

 Outlines :
 Infront : midline of the neck
 Behind and above :superior belly of
omohyoid muscle
 Behind and below : the sternomastoid
muscle
Contents of the Muscular triangle

 It contains the infrahyoid muscle

 Submental triangle

 Outlines :
 Infront : symphysis menti of the mandible
 On each side : the anterior belly of
digastric muscle
 Behind ( base ) : the hyoid bone
 Floor : parts of the mylohyoid muscles as
they meet each other in the median plane
Contents of the Submental triangle

 1- submental lymph nodes

 2- beginning of the anterior jugular vein
 The infrahyoid muscles

• They are strap like muscles occupy each side

of the midline of the neck , from the hyoid
bone to the manubrium sterni .
• They consist of 4 muscles arranged into 2
layers :
• 1- superficial layer : a- sternohyoid
• B- omohyoid
• 2- deep layer: a- sternothyroid
• B- thyrohyoid
The Hyoid Bone

• The only bone that does

not articulate with another
bone

• Serves as a moveable
base for the tongue

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

 The infrahyoid muscles

 Nerve supply :
 All The infrahyoid muscles are supplied by
 Ansa cervicalis except
thyrohyoid muscle supplied by fibres
from C1 through hypoglossal nerve .
 Ansa cervicalis

 Ansa = loop
 It is a loop of cervical nerve fibres derived from
C1,2,3 which lies below the carotid sheath
below the middle of the neck .
 It consists of 2 roots :
 1- descendes hypoglossi C1: derived from
hypoglossal nerve
 2- descendes cervicalis : C2,3 : from the
cervical plexus
 Action of the infrahyoid muscles

 1- superficial layer : a- sternohyoid : depress

the hyoid bone after it has been elevated
during swallowing .
 B- omohyoid : depresses , retracts and
steadies the hyoid bone .
 2- deep layer: a- sternothyroid : depress the
hyoid bone and the larynx
 B- thyrohyoid : depress the hyoid bone and
elevate the larynx
 Suprahyoid muscles

 1- digastric muscle
 2- mylohyoid muscle
 3- hyoglossus muscle
 4- geniohyoid muscle
 5- stylohyoid muscle
 Geniohyoid
muscle

Hyoglossus
 Digastric muscle

• It consists of 2 bellies anterior and posterior , that

connected together by an intermediate tendon .
• Nerve supply :
• 1- anterior belly : from nerve to mylohyoid which is
a branch of mandibular nerve .
• 2- posterior belly : the facial nerve
• Action :
• When the mandible is fixed , it raises the hyoid
bone during swallowing .
• When the hyoid bone is fixed , the anterior belly
can depress the mandible
• mylohyoid muscle :
• Formed of superoir and inferior bellies .
• Nerve supply : nerve to mylohyoid , which is
a branch of the mandibular nerve .
• Action :
• When the 2 bellies contract they elevate the
hyoid bone and the floor of the mouth as well
as the root of the tongue during swallowing .
• If the hyoid bone is fixed , the 2 bellies
depress the mandible and open the mouth .
 Hyoglossus muscle

 Nerve supply :
 Hypoglossal nerve ( 12th cranial nerve )
 Action :
 It draws the tongue downwards and thus
help suckling .
 Geniohyoid muscle :
 Nerve supply :
 Hypoglossal nerve ( via fibres from C1 )
 Action :
 It pulls the hyoid bone upwards and
forwards , if the hyoid bone is fixed , it
depresses the mandible .
 Stylohyoid muscle
 Nerve supply :
 Facial nerve
 Action :
 Raises the hyoid bone upwards