— Neck as seen from left anterior view. Drawing shows specific margins of anatomy seen in A that relate to definitions of classification levels. Note that line of separation between levels I and II is posterior margin of submandibular gland. Separation between levels II and III and IV is posterior edge of sternocleidomastoid muscle. Line of separation between levels IV and V is oblique line extending from posterior edge of sternocleidomastoid muscle to posterior edge of anterior scalene muscle. Posterior edge of internal jugular vein separates level IIA and IIB nodes. Carotid arteries separate levels III and IV from level VI. Top of manubrium separates levels VI and VII. (Reprinted with permission from )
Surface & radiological
Surface Markings & Vertebral LevelsC2- Angle of MandibleC3- Hyoid BoneC4- Thyroid NotchC6- Cricoid Cartilage; Trachea, Esophagus beginC7- Vertebra ProminensT2/3- Upper border of Manubrium /Suprasternal notchT3 & 4- Manubrium- overlies the aortic archT5 to 8- Sternum- overlies the heart
• Sternal Angle- T4/5- Approx level of 2 nd pair of costal cartilages; approx beginning and end of aortic arch; bifurcation of trachea in to Rt. & Lt. main bronchi.• Xiphisternal joint- T9• Lowest part of costal margin-10 th rib (the subcostal line)- passes through L3
• Scapula superior angle- T2 spine of scapula- T3 Inferior Angle- T7Esophagus: Approx length-25 cm Cervical: superiorly- just below the level of cricoid (cricopharyngeus muscle (C7))- 15 cm from incisors Inferiorly- Thoracic inlet approx 18 cm, T3 level at the level of suprasternal notch
• Thoracic Esophagus Superiorly- level of T3 (18 cm from incisors) Inferiorly- T10 or 11 Carina- 24-25 cm from incisors GE jn.- Approx 40 cm from incisorsAJCC Classification: Cervical (15-18 cm), upper Thoracic (18-24 cm), mid Thoracic (24-32), Lower Thoracic (32-40)
• Thorax- Lines of Orientation Midsternal Line- Lies in the Median Plane over the sternum Midclavicular Line- Runs vertically downward from the midpoint of the clavicle Anterior Axillary Line- Runs vertically downwards from the anterior axillary fold Posterior Axillary Line- Runs Vertically downwards from the posterior axillary fold
• Midaxillary Line- Runs vertically downward from a point situated midway between the anterior and posterior folds• Scapular Line- Runs vertically downward on the posterior wall of the thorax, passing through the inferior angle of the scapula (arms at sides)
• Nipple (in males)-lies in the 4th intercostal space about 10 cm from midline.• Apex Beat- in 5th intercostal space 9cm from midline (just below and medial to the nipple). Marks the lowest and outermost point at which the cardiac impulse can be palpated.
• Transpyloric Plane (of Addison)- Lies halfway between the suprasternal notch and pubis, or approx one hands breadth below the xiphoid (L1 Level) passes through the Pylorus, the pancreatic neck, the duodenojejunal flexure, the fundus of the gall bladder, the tip of the 9th costal cartilage, and hila of the kidneys. Also corresponds to the level of termination of the Spinal Cord.
• Subcostal Plane- L3 Line joining the lowest point of the thoracic cage on each side (inferior margin of the 10th rib).- passes through the origin of the inferior mesenteric artery.• Plane of the Iliac Crests- L4 Corresponds to the level of the Aortic bifurcation. Useful landmark in performing LP.
The Anterior Region of the Neck• Has several palpable landmarks, including the larynx, trachea, and sternal notch.• The larynx. – found in the middle of the neck – composed of multiple cartilages – thyroid cartilage • “Adam’s apple”• Inferior to the larynx are the cricoid cartilage and trachea.• Terminates at the sternal (jugular) notch of the manubrium and the left and right clavicles.
The Nuchal Region• The posterior neck region.• Houses the spinal cord, cervical vertebrae, and associated structures.• The bump at the lower boundary of this region is the vertebra prominens.• Superiorly along the midline of the neck, is the ligamentum nuchae, a thick ligament that runs from C7 to the nuchal lines of the skull.
Left and Right Lateral Portions of the Neck• Contain the sternocleidomastoid muscles which partitions the neck into two clinically important triangles, an anterior triangle and a posterior triangle.• Each triangle houses important structures that run through the neck.• Triangles are further subdivided into smaller triangles.• Anterior triangle lies anterior to the sternocleidomastoid muscle and inferior to the mandible. – subdivided into four smaller triangles • the submental, submandibular, carotid, and muscular triangles
The Posterior Triangle• Lateral region of the neck.• Posterior to the sternocleidomastoid muscle.• Superior to the clavicle inferiorly.• Anterior to the trapezius muscle.• Subdivided into two smaller triangles. – the occipital triangle – supraclavicular triangle
Position of Nodes 1. Submental 2. Submandibular 3. Parotid / tonsilar 4. Preauricular 5. Postauricular 6. Occipital 7. Anterior cervical superficial and deep 8. Supraclavicular 9. Posterior cervical
Gluteal Region• The inferior border of the gluteus maximus muscle forms the gluteal fold.• The gluteal (natal) cleft extends vertically to separate the buttocks into two prominences.• In the inferior portion of each buttock, an ischial tuberosity can be palpated; these tuberosities support body weight while seated.• The gluteus maximus muscle forms most of the inferolateral “fleshy” part of the buttock.• The gluteus medius muscle may be palpated only in the superolateral portion of each buttock.
The Thigh• Many muscular and bony features are readily identified in the thigh, which extends between the hip and the knee on each lower limb.• An extremely important element of thigh surface anatomy is a region called the femoral triangle.• The femoral triangle is a depression inferior to the groove that overlies the inguinal ligament on the anteromedial surface in the superior portion of the thigh.• The femoral artery, vein, and nerve travel through this region, making it an important arterial pressure point for controlling lower limb hemorrhage.
Thigh and Knee• On the distal part of the anterior thigh, are the three parts of the quadriceps femoris as they approach the knee.• Still on the anterior side of the thigh, three obvious skeletal features can be observed and palpated: – (1) The greater trochanter is palpated on the superior lateral surface of the thigh; – (2) the patella is located easily within the patellar tendon; and – (3) the lateral and medial condyles of both the femur and tibia are identified and palpated at each knee.
Level Ia Level Ia CRANIAL Geniohyoid m., plane tangent to basilar edge of mandible CAUDAL Plane tangent to body of hyoid bone ANTERIOR Symphysis menti, platysma m. POSTERIOR Body of hyoid bone LATERAL Medial edge of ant. belly of digastric MEDIAL n.a. (midline)
Level Ib Level Ib CRANIAL Mylohyoid m., cranial edge of submandibular gland CAUDAL Plane through central part of hyoid bone ANTERIOR Symphysis menti, platysma m. POSTERIOR Posterior edge of submandibular gland LATERAL Basilar edge / innerside of mandible, platysma m., skin MEDIAL Lateral edge of ant. belly of digastric
Level IIa Level IIa CRANIAL Caudal edge of lateral process of C1 CAUDAL Caudal edge of the body of hyoid bone ANTERIOR Post. edge of submandibular gland; ant. edge of int. carotid artery;IIA post. edge of post. belly of digastric m. POSTERIOR Post. Border of int. jugular vein LATERAL Medial edge of sternocleidomastoid MEDIAL Medial edge of int. carotid artery, paraspinal (levator scapulae) m.
Level IIb Level IIb CRANIAL Caudal edge of lateral process of C1 CAUDAL Caudal edge of the body of hyoid bone ANTERIOR Post. Border of int. jugular vein POSTERIOR Post. border of theIIB sternocleidomastoid m. LATERAL Medial edge of sternocleidomastoid MEDIAL Medial edge of int. carotid artery, paraspinal (levator scapulae) m.
Level III III CRANIAL Caudal edge of the body of hyoid bone CAUDAL Caudal edge of cricoid cartilage ANTERIOR Postero-lateral edge of the sternohyoid; ant. edge of sternocleidomastoid m. POSTERIOR Post. edge of the sternocleidomastoid LATERAL Medial edge of sternocleidomastoid MEDIAL Int. edge of carotid artery, paraspinal (scalenius) m.
Level IV Level IV CRANIAL Caudal edge of cricoid cartilage CAUDAL 2 cm cranial to sternoclavicular joint ANTERIOR Anteromedial edge of sternocleido- mastoid m POSTERIOR Post. edge of the sternocleidomastoid m. LATERAL Medial edge of sternocleidomastoid MEDIAL Medial edge of internal carotid artery, paraspinal (scalenius) m.
Level V Level VCRANIAL Cranial edge of body of hyoid boneCAUDAL CT slice encompassing the transverse cervical vesselsbANTERIOR Post. edge of the sternocleidomastoid m.POSTERIOR Ant. border of the trapezius m.LATERAL Platysma m., skinMEDIAL Paraspinal (levator scapulae, splenius capitis) m.
Level VI Level VI CRANIAL Caudal edge of body of thyroid cartilage CAUDAL Sternal manubrium ANTERIOR Skin; platysma m. POSTERIOR Separation between trachea and esophagus LATERAL Medial edges of thyroid gland, skin and ant.-medial edge of sternocleidomastoid m. MEDIAL n.a.
Retropharyngeal nodes Retropharyngeal CRANIAL Base of skull CAUDAL Cranial edge of the body of hyoid bone ANTERIOR Fascia under the pharyngeal mucosa POSTERIOR Prevertebral m. (longus colli, longus capitis) LATERAL Medial edge of the internal carotid artery MEDIAL Midline