Download MBBS Deep Fascia of the Neck Lecture PPT

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fascia.

? It splits to enclose the thyroid gland forming its

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capsule and is attached to the oblique line of

thyroid cartilage and to the arch of cricoid cartilage

anteriorly.

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? Ligament of Berry is derived from this fascia and

connects the capsule of the lateral lobe of the

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thyroid gland to the cricoid cartilage

? Tracing of the pretracheal fascia
? Horizontal tracing:
? It merges with the investing layer of deep cervical

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fascia enclosing the sternocleidomastoid and the

anterior wall of the carotid sheath.

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? Vertical tracing:
? It is attached to the hyoid bone and when traced

below, it enters the thorax in front of the trachea

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and blends with the apex of the fibrous

pericardium.
? Prevertebral fascia
? It is extremely strong and lies in front of the

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prevertebral muscles

? Tracing of the prevertebral fascia
? Horizontal tracing:

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? It forms the fascial carpet of the posterior triangle.
? It also forms axillary sheath, which may extend up

to the elbow.

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? Subclavian and axillary veins lie outside the sheath
? Vertical tracing:
? Traced aboveextends up to the base of the skull

to which it is attached.

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? Traced below continues downwards and blends

with the anterior longitudinal ligament of the upper

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thoracic vertebrae (T1 to T3).
Retropharyngeal space

? Anteriorly, the prevertebral layer of deep cervical

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fascia is separated from posterior aspect of the

pharynx and its covering, buccopharyngeal fascia,

by a potential space called retropharyngeal space.

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? The retropharyngeal space is continuous with the

parapharyngeal spaces at the sides of the pharynx.

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? The retropharyngeal space is divided into two

lateral compartments (spaces of Gillette) by a

midline fibrous raphe.

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? The space behind the prevertebral fascia and in

front of the vertebral bodies is called prevertebral

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space.

SIDE OF THE NECK

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Side of the Neck

? Quadrangular in shape.
? It is bounded
? Anteriorly anterior midline

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of the neck

? Posteriorly anterior border

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of the trapezius

? Superiorly lower border of

the body of the mandible and

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a line extending from the

angle of the mandible to the

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mastoid process

? Inferiorly clavicle.

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Triangles on the side of the neck

? This quadrilateral area

is divided into large

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anterior and posterior

triangles by the

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sternocleidomastoid

muscle

? Which runs across this

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area diagonally from

mastoid process to

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the upper end of the

sternum.

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Sternocleidomastoid Muscle

Origin

Sternal headarises by a rounded

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tendon from the superolateral part

Of the front of the manubrium

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sterni, below the suprasternal notch.

Clavicular head flat and

musculoaponeurotic. It arises from

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the medial third of the superior

surface of the clavicle.

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Insertion

by a thick tendon on the lateral

surface of the mastoid process and by

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a thin aponeurosis into the lateral

half

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of the superior nuchal line of the

occipital bone
? Arterial Supply
? The sternocleidomastoid is supplied by branches of

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following arteries:

Upper part occipital and posterior auricular art.
Middle part superior thyroid artery.

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Lower part suprascapular artery.
? Nerve Supply
? Supplied by the spinal accessory nerve.
? It is also supplied by the ventral rami of C2 and C3,

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which are mostly sensory and carry proprioceptive

sensations from the muscle.
? Actions
? When muscle acting alone , it tilts the head towards

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the shoulder on the same side and rotates the head

so that chin turns to the opposite side. This

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movement occurs during an upward sideways glance.

? When muscles of both sides contract together they

draw the head forwards as in lifting the head from

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the pillow or bending the head during eating food.

? If the head is fixed by prevertebral muscles, the two

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sternocleidomastoid muscles act as accessory

muscles of respiration during forced inspiration.
Torticollis or wry neck

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? Head is bent to one side and chin points to the opposite side.
? This occurs due to spasm of sternocleidomastoid and

trapezius muscles supplied by spinal accessory nerve.

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? Spasmodic torticollis is characterized by repeated painful

contractions of the trapezius and sternocleidomastoid

muscles on one side. Caused by exposure to cold and

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maladjustment of pillow during sleep.

? Reflex torticollis occurs due to irritation of spinal accessory

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nerve caused by inflamed or suppurating lymph nodes.

? Congenital torticollis occurs due to birth injury to muscle.

Permanent torticollis may occur due to subsequent ischemic

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contracture
POSTERIOR TRIANGLE

? It is the triangular space on the side of neck behind the

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sternocleidomastoid muscle. Its apex is directed

upwards and backwards towards the mastoid process

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and base downwards towards the clavicle.

? Boundaries
? Anterior: Posterior border of sternocleidomastoid

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muscle.

? Posterior: Anterior border of trapezius muscle.
? Inferior (base): Superior aspect of middle third of the

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clavicle.

? Superior (apex): Meeting point of sternocleidomastoid

and trapezius muscles at the superior nuchal line of the

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occipital bone

? Roof
? Formed by investing layer of the deep cervical fascia

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? superficial fascia overlying the roof contains platysma,

external jugular and posterior jugular veins, and

cutaneous nerves and vessels.

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? Structures piercing the roof of the posterior triangle

are

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1. Four cutaneous branches of cervical plexus

(a) Lesser occipital nerve (C2)

(b) Great auricular nerve (C2, C3)

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(c) Transverse cervical nerve (C2, C3)

(d) Supraclavicular nerves (C3, C4).

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2. External jugular vein

? Floor
? The floor of posterior triangle is muscular.
? Formed from above downwards by

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1. Semispinalis capitis.
2. Splenius capitis.
3. Levator scapulae.
4. Scalenus medius.
5. First digitation of serratus anterior (sometimes).

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? Fascial carpet of the posterior triangle
? The muscular floor of posterior triangle is covered

by prevertebral layer of deep cervical fascia, which

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forms the fascial carpet of the floor of the

posterior triangle.

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? It forms axillary sheath around subclavian artery

and brachial plexus travelling from the root of the

neck to the upper limb.

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? The lower part of the posterior triangle is crossed

by inferior belly of omohyoid superficial to the

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fascial carpet.

? Subdivisions
? The posterior triangle is subdivided into two

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parts by the inferior belly of the omohyoid.

? (a) occipital triangle a upper larger part.
? (b) subclavian (supraclavicular) triangle small

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lower part.

? These parts are so named because they contain

occipital and subclavian arteries, respectively.

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? Contents
1. In the occipital triangle

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(a) Spinal accessory nerve
(b) 3rd and 4th cervical nerves providing branches to
levator scapulae and trapezius muscles
(c) Dorsal scapular nerve (C5)
(d) Four cutaneous branches of cervical plexus (initial

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parts)
(e) Superficial transverse cervical artery
(f) Occipital artery

2. In the subclavian(supraclavicular triangle)

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(a) 3rd part of the subclavian artery
(b) Subclavian vein
(c) Terminal part of external jugular vein
(d) Trunks of brachial plexus
(e) Superficial (transverse) cervical, suprascapular,

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and dorsal scapular arteries

(f) Lymph nodes
? All the important contents of the posterior triangle

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lie deep to the fascial carpet of the floor

? except spinal accessory nerve, which lies just

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underneath the roof.

? In operations on the posterior triangle all the

structures except spinal accessory nerve are safe,

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provided fascial carpet of posterior triangle is left

intact.

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Spinal accessory nerve

? This nerve emerges in the

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posterior triangle by piercing

the posterior border of the

sternocleidomastoid (a little

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above the middle of this

border).

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? It is related to lymph nodes of

the upper deep cervical chain .

? The nerve running downwards

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parallel to the fibres of levator

scapulae muscle to

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? Disappear underneath to the

anterior border of trapezius and

supplies trapezius muscle.

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? In the posterior triangle it is

adherent to the deep aspect of

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the fascial roof of this triangle.


Four cutaneous branches of cervical plexus

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? It emerge at the midpoint (just above)

of the posterior border of the

sternocleidomastoid by piercing the

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deep cervical fascia.

(a)lesser occipital nerve
auricle and head behind the auricle.

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(b) great auricular nerve
anterior and posterior branches.
skin on angle of the mandible

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mastoid

region and auricle (lower part).

(c) transverse cervical nerve

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ascending and descending br.
skin of the front of the neck.

(d) supraclavicular nerve
medial, intermediate, lateral

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supraclavicular

skin on chest up to the 2nd rib, front of

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the chest, deltoid muscle(upper half)
? Transverse cervical artery: branch of thyrocervical

trunk of the first part of subclavian artery.

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? Suprascapular artery: branch of thyrocervical trunk

? Dorsal scapular artery: It arises from the third part

of the subclavian artery.

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? Occipital artery: branch of external carotid artery

? Subclavian artery

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Lymph nodes

? These are deep cervical lymph

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nodes found at the following

sites in the posterior triangle:

(a) A chain of nodes along the

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posterior border of

sternocleidomastoid.

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(b) A chain of nodes along the

spinal accessory nerve.

(c) A few nodes in the apical

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region of the triangle called

occipital lymph nodes.

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(d) A group of supraclavicular

lymph nodes.

? These nodes lie superficial to

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brachial plexus and subclavian

vessels.
Swelling in the posterior triangle

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? Most common cause of swelling in the posterior

triangle is due to enlargement of lymph nodes.

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? Supraclavicular lymph nodes are commonly

involved and enlarged in tuberculosis, Hodgkin's

disease, and malignant growth of breast, arm, and

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chest.

? Left supraclavicular lymph nodes (Virchow's lymph

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nodes) are commonly involved in metastasis from

cancer stomach, cancer testis, and cancer of other

abdominal organs.

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? The biopsy of these lymph nodes is helpful in early

diagnosis of distant malignancies.