surgical anatomy of neck

1. DR SATINDER PAL SINGH

4. SURFACE ANATOMY OF NECK

6. The neck is a biomechanical wonder!
 Connects the head to the trunk
 Conduit for blood vessels, nerves, and hollow
organs
 All of these complicated structures are packed in a
very narrow area that allows for a great deal of
mobility for the head as it moves relative to the
ground

7. FASCIA
 The neck is divided into anatomical
compartments by strong fascia, which is
arranged in layers and tends to align neck
structures in bundles. These are real and
important anatomical divisions and have
great relevance clinically.
 The superficial fascia in the neck
contains a thin sheet of muscle (the
platysma).

10. Deep Cervical Fascia
 Form the boundaries of compartments
 Fascial spaces can communicate infection or
fluid to other regions of the body
 Used as a guide to surgical dissection
 Allow the neck structures to glide past one
another
 Supports the thyroid, lymph nodes and blood
vessels

12. Deep Fascia
 an investing layer, which surrounds all structures in
the neck;
 the prevertebral layer, which surrounds the
vertebral column and the deep muscles associated
with the back;
 the pretracheal layer, which encloses the viscera of
the neck; and
 the carotid sheaths, which receive a contribution
from the other three fascial layers and surround the
two major neurovascular bundles on either side of the
neck.

13. Deep Cervical Fascia

14. Deep Cervical Fascia

17. Deep Cervical Fascial Spaces
 Retropharyngeal - b/n prevertebral and
buccopharyngeal
 Pretracheal - b/n infrahyoids and trachea
 Lateral pharyngeal - lat to pharynx and
communicate with RP and SM spaces
 Submandibular - below tongue
 deep portion above mylohyoid
 superficial portion below mylohyoid

26. Platysma
•Muscle of Facial Expression
•Innervated by the cervical branch of the facial nerve

27. Sternocleidomastoid
The sternomastoid muscle
divides the neck into two
anatomical triangles.
•Flexes and rotates the head
•Innervation is by CN XI

29. Trapezius
•Moves and stabilizes the scapula, extends the head
•Innervation is by CNXI

30. Deep Cervical (Prevertebral) Muscles

34. Submental Triangle

36. Submandibular Triangle

37. Submandibular Abscess in a person with Diabetes

38. Patient with submandibular space abscess or
Ludwig’s angina who required a tracheostomy.

39. Carotid Triangle

42. Muscular Triangle

43. SUPRAHYOID MUSCLES

44. Suprahyoid Muscles

45. Suprahyoid Muscles
(geniohyoid)

46. Infrahyoid (Strap) Muscles

48. Actions of Suprahyoid and Infrahyoid Muscles

51. Branches of the external carotid
artery
 superior thyroid artery
 ascending pharyngeal artery
 lingual artery
 facial artery
 occipital artery
 posterior auricular artery
 superficial temporal artery
 maxillary artery

54. Veins
 Collecting blood from the skull, brain, superficial face,
and parts of the neck, the internal jugular vein.
 The paired internal jugular veins join with the
subclavian veins posterior to the sternal end of the
clavicle to form the right and left brachiocephalic
veins.
 Tributaries to each internal jugular vein include the
inferior petrosal sinus, and the facial, lingual,
pharyngeal, occipital, superior thyroid, and
middle thyroid veins.

58. Innervation and Venous Drainage of the Neck

59. PHARYNX
 The is a musculofascial half-cylinder that
links the oral and nasal cavities in the head
to the larynx and esophagus in the neck.
 The pharyngeal cavity is a common pathway
for air and food.

60. PHARYNGEAL WALL
 The pharyngeal wall is formed by skeletal
muscles and by fascia.
 Gaps between the muscles are reinforced by
the fascia and provide routes for structures
to pass through the wall.

67. Superficial lymphatics of the neck. sme, submental; sma,
submandibular; f, facial; ej, external jugular; aj, anterior jugular; o,
occipital; m, mastoid; p, parotid.

68. Deep lymphatics of the neck. IJ, internal jugular chain; SA,
spinal accessory chain; TC, transverse cervical chain; dn,
Delphian node.

69. Cervical levels according to Robbins

71. Classification of Neck Dissections
• Classic radical neck dissection remove cervical lymph nodes from
levels I to V.
• Extended radical neck dissection L.N. I-V +SAN+SCM+IJV
L.N VIII reteropharyngeal
Hypoglossal N.
Carotid A.
Skin of neck
Modified radical neck dissection type I
(MRND-I)
selectively preserves the spinal
accessory nerve (SAN)
MRND-II Preserves SAN + SCM
MRND-III preserves SAN+ SCM+ IJV
Comprehensive Neck Dissection

72. Selective Neck Dissection
Supraomohyoid neck dissection, lymph nodes at levels I, II, and III
for primary tumors of the oral cavity
Jugular node dissection levels II, III, and IV for primary tumors
of the hypopharynx and larynx
Anterolateral neck dissection, lymph nodes at levels I, II, III, and IV
for primary tumors of the oral cavity
and oropharynx
Posterolateral neck dissection Lymph nodes in the suboccipital
triangle, posterior triangle of the
neck, level V,
Central compartment neck dissection, lymph nodes at level VI in the central
compartment of the neck adjacent to
the thyroid gland and in the
tracheoesophageal groove for thyroid
cancer

73. Cervical lymph node groups removed in
various types of neck dissection.

74. The most commonly used incisions for various types of neck
dissections.
A, Supraomohyoid neck dissection. B, Supraomohyoid neck
dissection with a parotidectomy. C, Supraomohyoid neck
dissection with extension for submental dissection.

75. D, Jugular node dissection.
E, Comprehensive neck dissection. F, Comprehensive neck
dissection with a thyroidectomy.

76. SELECTIVE NECK DISSECTION LEVELS I-III.

77. SELECTIVE NECK DISSECTION LEVELS II-IV

78. SELECTIVE NECK DISSECTION II-V, POSTAURICULAR,
SUBOCCIPITAL, OR POSTEROLATERAL NECK DISSECTION

79. SELECTIVE NECK DISSECTION VI, OR ANTERIOR NECK
DISSECTION

80. Pattern of lymphatic flow as demonstrated by
Fisch.

81. PATTERNS OF NECK METASTASIS
Primary site First echelon
lymph nodes
Oral cavity
Submandibular gland
Sublingual gland
• Level I
• Level II
• Level III
Parotid • Preauricular
• Periparotid & intraparotid
• Level II
• Level III
• Upper accessory chain
Larynx
Pharynx
• Level II
• Level III
• Level IV
Thyroid • Perithyroid nodes
• Tracheoesophageal groove
• Level VI

82. INCISION AND FLAPS OF NECK
 Allow adequate exposure of the surgical field.
 Assure adequate vascularization of the skin flaps.
 Protect the carotid artery if the sternocleidomastoid
muscle has to be sacrificed.
 Include scars from previous procedures (e.g., surgery,
biopsy, etc.).
 Consider the location of the primary tumor.
 Facilitate the use of reconstructive techniques.
 Contemplate the potential need of postoperative
radiotherapy.
 Produce acceptable cosmetic results.

83. Some popular skin incisions for functional and selective neck dissection.
(A) Gluck incision
for unilateral and bilateral neck dissection. B) Double-Y incision of Martin.
(C) Single-Y incision (D) Schobinger incision.

84. E) Conley incision.
F) Mac Fee incision.
The Mac Fee incision has
excellent cosmetic results.
(G) H incision.

85. The double-Y incision of Martin is also popular
for functional and selective neck dissection.

86. The single-Y incision avoids one of the crossings of the
double-Y incision but makes the dissection of the
supraclavicular fossa difficult.

87. A popular incision in our practice is the classic Gluck incision
For a bilateral functional neck dissection the incision extends
between both mastoid tips, crossing the midline at the level
of the cricoid arch. This incision allows good exposure when
the neck dissection is to be combined with total or partial
laryngectomy.

88. Cutaneous line of incision
1 = manubrium sterni
2 = clavicle
3 = acromioclavicular joint
4 = anterior margin of trapezius
muscle
5 = mastoid

89. Anaplastic thyroid cancer presents as a rapidly enlarging neck mass (A). Establishing a
surgical airway can be challenging due to signifi cant tracheal deviation

90. Low Kocher’s incision for Thyroidectomy
A skin incision is made in, or closely paralleling, a low anterior neck skin
crease (Kocher’s incision)

91. Incision for parotidectomy.

92. A patient with enlargement of the right submandibular salivary
gland. The surface markings indicate the angle of the mandible
and the proposed line of incision.

93. Right branchial cyst.
Right cervical tuberculous adenitis with
central necrosis (scrofula).

94. Dermoid cyst.
Infected thyroglossal duct cyst.