The NECK_Rmin Sheila Miranda
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NECK and CERVICAL LYMPHATICS
Miranda, Rmin Sheila J.Medicine 2009 (August 2008)
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OVERVIEW
Function Topographic Anatomy Fascial Layers Neck Triangles Cervical Lymphatics
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THE NECK
Communication between head and body: For air For food For speech
Contains: Major blood vessels Nerves and the spinal cord Cervical lymphatics
For maximal mobility to permit variation in head position relative to body
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Topographic Anatomy
Superior: inferior border of the mandible tip of the mastoid process external occipital protuberance
Lateral: sternocleidomastoid muscles trapezius muscles
Medial: hyoid bone thyroid cartilage cricoid cartilage thyroid gland (if enlarged)
Inferior: suprasternal notch upper border of the clavicle
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Fascial Layers of the Neck
Superficial Fascia Thin layer that encloses platysma ms. Contains cutaneous vessela and nodes
Deep Cervical Fascia (Fascia Colli) Superficial investing
Complete encircles the neck Encloses SCM and trapezius ms Roofs over Anterior and Posterior neck triangles
Pretracheal layer Encloses infrahyoid ms, thyroid and parathyroid glands Blends inferiorly with fibrous pericardium
Prevertebral layer Covers prevertebral ms
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Fascial Layers of the Neck
Pretracheal Fascia
Superficial Fascia
Prevertebral Fascia
Superficial InvestingFascia
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Fascial Layers of the Neck
Pretracheal Fascia
Superficial Fascia
Prevertebral Fascia
Superficial InvestingFascia
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Neck Triangles
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Anterior Neck Triangle
Borders A: midline of the neck P: anterior border of SCM S: lower margin of the mandible
Divided by Anterior & Posterior bellies of
digastric muscle Superior belly of omohyoid muscle
Subdivisions Submental triangle Digastric/submandibular triangle Carotid triangle Muscular triangle
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Subdivisions of ANT
Submental Triangle
Borders anterior belly of digastric ms,
hyoid, and midline floor formed by 2 Mylohyoid ms
Contents submental lymph nodes
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Subdivisions of ANT
Digastric / Submandibular Triangle
Borders: mandible, anterior and posterior belly of digastric ms floor formed by the mylohyoid and hyoglossus muscles
Contents: A: submandibular salivary gland, facial artery, facial vein, and
submandibular lymph nodes I: Nerve and vessels to the mylohyoid muscles P: carotid sheath with the carotid arteries, internal jugular vein, and
vagus nerve Lower part of the parotid gland projects into the triangle Hypoglossal nerve runs on the hyoglossus muscle
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Subdivisions of ANT
Carotid Triangle
Borders: Posterior belly of digastric ms, superior belly of omohyoid ms, and
anterior border of SCM Floor formed by portions of the thyrohyoid, hyoglossus, and middle
and inferior constrictor muscles of the pharynx
Contents: carotid sheath (where common carotid artery divides into ICA & ECA) branches of ECA internal jugular vein hypoglossal nerve, laryngeal nerves, accessory and vagus nerves part of the chain of deep cervical lymph nodes
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Subdivisions of ANT
Muscular Triangle
Borders: A: midline of neck S: superior belly of omohyoid ms I: anterior border of SCM Floor formed by the sternohyoid and sternothyroid ms.
Contents: thyroid gland larynx trachea
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Posterior Neck Triangle
Borders A: posterior border of SCM P: anterior border of trapezius ms I: middle third of the clavicle
Divided by Inferior belly of omohyoid ms
Subdivisions Occipital triangle Supraclavicular triangle
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Subdivisions of PNT
Supraclavicular Triangle
Borders A: posterior border of SCM P: inferior belly of omohyoid ms I: clavicle
Contents Superficially crossed by the suprascapular artery with the subclavian
artery deeper inside
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Subdivisions of PNT
Occipital Triangle
Borders A: posterior border of SCM P: anterior border of trapezius ms I: inferior belly of the omohyoid
Contents Occipital artery appears at its apex Crossed by the accessory nerve
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CERVICAL LYMPHATICS
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Cervical LN Groups
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HEAD LYMPHATIC NODES
Efferent drainage: cervical nodes
1-3 occipital nodes: back of head
2 post-auricular: insertion site of SCM
Pre-auricular: anterior to tragus
Parotid nodes Superficial nodes: within
gland substance Deep nodes: lateral wall of
the pharynx
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HEAD LYMPHATIC NODES
Deep cervical chain through the submandibular nodes Infra-orbital Buccinators Supramandibular Submental nodes
Primary deep lymphatic chains of the neck Internal jugular spinal accessory transverse cervical are the
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INTERNAL JUGULAR CHAIN
Chief collecting system 10-20 nodes on each
side Highest: parapharyngeal
and retropharyngeal nodes
Superior group Anterior or lateral to IJV Most frequently involved in
aerodigestive squamous cell CA
Inferior group Anterior and medial to IJV Close to trachea
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TRANSVERSE CERVICAL CHAIN
4-12 nodes Connects spinal accessory
with internal jugular chain Empty into lymphatic trunk
L: thoracic duct R: lymphatic duct
Supraclavicular (Virchov’s) nodes receive lymph from: below the clavicles head and neck upper extremities
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CERVICAL LN GROUPS
Level I Submental &
Submandibular group Level II
Upper jugular group Level III
Middle jugular group Level IV
Lower jugular group Level V
Posterior triangle group Level VI
Anterior compartment group
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LEVEL IA: Submental nodes
3-4 Between anterior belly of
digastric ms Drains:
incisor region of lower gums Lips tip of tongue ventral part of mouth floor skin of cheek
Efferents to submandibular nodes and deep cervical chain
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LEVEL IB: Submandibular nodes
3-6 inferior border of mandible Drains:
medial palp. eye commissure cheek and chin side of nose upper and lateral lower lip gums and teeth anterior part of tongue margin (not
tip) paranasal sinuses
Efferent vessels pass to superficial and superior deep cervical nodes
Boundaries: Body of the mandible Anterior belly of contralateral
digastric muscle Anterior & Posterior bellies of
ipsilateral digastric muscle
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LEVEL II: UPPER JUGULAR
At upper 1/3 of IJV, near SAN extending from :
level of carotid bifurcation (surgical landmark) or
hyoid bone (clinical landmark) inferiorly to skull base superiorly
L: Posterior border of SCM M: Lateral border of sternohyoid &
stylohyoid ms
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LEVEL III: MIDDLE JUGULAR
At middle 1/3 of IJV Extends from:
extending from carotid bifurcation superiorly (surgical landmark) or
hyoid bone (clinical landmark) to junction of omohyoid ms with IJV (surgical landmark) or cricothyroid membrane (clinical landmark) inferiorly
L: Posterior border SCM M: Lateral border of sternohyoid
ms
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LEVEL IV: LOWER JUGULAR
At lower 1/3 of IJV Extending from:
omohyoid ms superiorly to clavicle inferiorly
L:Posterior border of SCM A: Lateral border of
sternohyoid ms
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LEVEL V: POSTERIOR TRIANGLE
Boundaries L: Anterior border of
trapezius ms M: Posterior border of SCM I: Clavicle
3 predominant lymphatic pathways SAN as it traverses posterior
triangle transverse cervical artery as
it courses lower 1/3 triangle Supraclavicular nodes
located above lateral 2/3 of clavicle
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VI
LEVEL VI: ANTERIOR COMPARTMENT
At midline visceral neck structures Extends from
S: hyoid bone I: suprasternal notch
Boundaries L: Medial border of carotid sheath
Located within this compartment Perithyroidal lymph nodes Paratracheal lymph nodes Lymph nodes along RLN Precricoid (Delphian) lymph node
Pathways of spread from primary cancers originating in: thyroid gland apex of piriform sinus subglottic larynx cervical esophagus cervical trachea
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THE END
Thank you!