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Triangles of Neck
Dr. Rabia Inam Gandapore
Assistant Professor
Head of Department Anatomy
(Dentistry-BKCD)
B.D.S (SBDC), M.Phil. Anatomy (KMU),
Dip. Implant (Sharjah, Bangkok, ACHERS) , CHPE
(KMU),CHR (KMU), Dip. Arts (Florence, Italy)
Teaching Methodology
 LGF (Long Group Format)
 SGF (Short Group Format)
 LGD (Long Group Discussion, Interactive discussion with the use of models or diagrams)
 SGD (Short Group)
 SDL (Self-Directed Learning)
 DSL (Directed-Self Learning)
 PBL (Problem- Based Learning)
 Online Teaching Method
 Role Play
 Demonstrations
 Laboratory
 Museum
 Library (Computed Assisted Learning or E-Learning)
 Assignments
 Video tutorial method
Goal/Aim (main objective)
To help/facilitate/augment the students about the:
 Describe superficial fascia & deep fascia.
 Enlist subdivisions of anterior triangle of neck
a. Submental Triangle
b. Digastric triangle
c. Carotid Triangle
d. Muscular Triangle
 Describe boundaries & content of anterior triangle of
neck.
 Describe boundaries & content of carotid triangle of neck.
 Describe boundaries & content of muscular triangle
 Describe attachments, nerve
supply & actions of infrahyoid
muscles.
 Enumerate clinical problems
related to anterior neck region.
 Describe boundaries, divisions &
contents of posterior triangle.
 Discuss swelling of
supraclavicular lymph nodes.
Specific Learning Objectives (cognitive)
At the end of the lecture the student will able to:
 Describe superficial fascia & deep fascia.
 Enlist subdivisions of anterior triangle of neck
a. Submental Triangle
b. Digastric triangle
c. Carotid Triangle
d. Muscular Triangle
 Describe boundaries & content of anterior triangle of neck.
 Describe boundaries & content of carotid triangle of neck.
 Describe boundaries & content of muscular triangle
 Describe attachments, nerve supply & actions of infrahyoid muscles.
 Enumerate clinical problems related to anterior neck region.
 Describe boundaries, divisions & contents of posterior triangle.
 Discuss swelling of supraclavicular lymph nodes.
Psychomotor Objective: (Guided response)
 A student to draw labelled diagram of the triangles of neck
Affective domain
 To be able to display a good code of conduct and moral values in the class.
 To cooperate with the teacher and in groups with the colleagues.
 To demonstrate a responsible behavior in the class and be punctual, regular, attentive and on time in the class.
 To be able to perform well in the class under the guidance and supervision of the teacher.
 Study the topic before entering the class.
 Discuss among colleagues the topic under discussion in SGDs.
 Participate in group activities and museum classes and follow the rules.
 Volunteer to participate in psychomotor activities.
 Listen to the teacher's instructions carefully and follow the guidelines.
 Ask questions in the class by raising hand and avoid creating a disturbance.
 To be able to submit all assignments on time and get your sketch logbooks checked.
Lesson contents
Clinical chair side question: Students will be asked if they know what is the function of triangles of neck
Outline:
 Activity 1 The facilitator will explain the student's Triangles of Neck in detail
 Activity 2 The facilitator will ask the students to locate triangles of Neck on Model
 Activity 3 The facilitator will ask the students a few Multiple Choice Questions related to it with flashcards.
Recommendations
 Students assessment: MCQs, Flashcards, Diagrams labeling.
 Learning resources: Langman’s T.W. Sadler, Laiq Hussain Siddiqui, Snell Clinical Anatomy, Netter’s Atlas,
BD Chaurasia’s Human anatomy, Internet sources links.
Introduction
 Side of neck presents a quadrilateral outline.
Its limited:
 Above: by lower border of body of mandible
& an imaginary line drawn from angle of
mandible to mastoid process.
 Below: limited by upper border of clavicle.
 Medially: by midline of neck.
 Posteriorly: by anterior border of Trapezius
muscle .
Sternocleidomastoid & Trapezius Muscles
 Large superficial
muscles of neck.
 Both of them are
supplied by spinal root of
accessory nerve.
Sternocleidomastoid
 This quadrilateral space is divided by
Sternocleidomastoid muscle into 2
triangles .
 It passes obliquely upwards and
backwards from its site of origin at
clavicle & sternum to its point of
insertion on the mastoid process &
occipital bone .
 The triangle in front of this muscle is
the anterior triangle & behind it is the
posterior triangle .
Sternocleidomastoid
 Origin:
1. Sternal head arises from
superolateral part of front of
manubrium sterni.
2. Clavicular head arises from
medial1/3rd of superior surface of
clavicle.
 Between two heads, there is a
small triangular depression of
lesser supraclavicular fossa,
overlying internal jugular vein
 Insertion:
1. By a thick tendon into lateral surface of
mastoid process, from its tip to superior
border.
2. By a thin aponeurosis into lateral half of
superior nuchal line of occipital bone.
 Nerve Supply:
1. Spinal accessory nerve (motor supply). It
passes through muscle.
2. Branches from ventral rami of C2 & C3
are proprioceptive.
 Blood Supply
Arterial supply: one branch each from
superior thyroid artery & suprascapular
artery and, two branches from occipital
artery supply big muscle.
Veins: follow arteries
 Actions:
1. Unilateral contracts:
a. It turns chin to opposite side.
b. It can also tilt head towards shoulder
of same side.
2. Bilateral contract together:
a. They draw the head forwards, as in
eating & in lifting head from a pillow.
b. With longus colli, they flex the neck
against resistance.
c. It also helps in forced inspiration
 Relations: sternocleidomastoid is enclosed in investing layer of deep cervical fascia
& is pierced by accessory nerve & four sternocleidomastoid arteries. It has following
relations.
 Superficial:
1. Skin
2. Superficial fascia & Superficial lamina of deep cervical fascia
3. Platysma
4. External jugular vein & superficial cervical lymph nodes.
5. Cervical Plexus: Great auricular, Transverse or anterior cutaneous, Medial
supraclavicular nerves & Lesser occipital nerve
6. Parotid gland overlaps muscle.
 Deep:
1 Bones and joints: Above: Mastoid process, Below: Sternoclavicular joint
2 Carotid sheath
3 Muscles: Sternohyoid, Sternothyroid, Omohyoid, 3 scalene, Levator scapulae,
Splenius capitis, Longissimus capitis, Posterior belly of digastric.
 4. Arteries: Common carotid (Internal
carotid & External carotid),
Sternocleidomastoid arteries (2 from
occipital artery, 1 from superior thyroid, 1
from suprascapular), Occipital, Subclavian,
Suprascapular & Transverse cervical
5. Veins: Internal jugular , Anterior jugular,
Facial, Lingual
6. Nerves: Vagus, Parts of IX (GP), XI (SA),
XII (HG), Cervical plexus (Ansa cervicalis &
Phrenic), Upper part of brachial plexus,,
7. Lymph nodes: superficial & deep
cervical .
Clinical Relevance
 Sucide attempts fail as
it’s a thick muscle
protecting the underlying
structures. And only
succeed if greater part of
sternocleidomastoid
muscle & larynx have been
severed
Torticollis
 Spasmodic Torticollis (Twisted-Neck Collar):
deformity in which head is bent to one side &
chin points to other side.
 Cause: spasm or contracture of muscles
supplied by spinal accessory nerve, these being
sternocleidomastoid & trapezius.
 Many Types of torticollis but common types are:
a. Rheumatic torticollis: due to exposure to
cold or draught.
b. Reflex torticollis: due to inflamed or
suppurating cervical lymph nodes which irritate
spinal accessory nerve.
Anterior Triangle Of Neck
Boundaries
 Posteriorly (Lateral) By: Ant border of
Sternocleidomastoid
Anteriorly (Medial) By: Midline of Neck
Superiorly By: Lower Margin of body of mandible
 Coverings: Skin, Superficial Fascia, Platysma &
Investing layer of deep fascia running across the
triangle in this coverings are cervical branch of
facial nerve & transverse cutaneous nerve.
 Sub- divided into smaller triangles by:
 Anterior & Posterior bellies of digastric muscle
 Superior belly of omohyoid muscle
a. Submental Triangle
 Median triangle
 Boundries:
Anteriorly: Midline of the neck
Laterally: Anterior belly of digastric
Inferiorly (base): Body of hyoid bone
Floor: Mylohyoid muscle & median raphe attached
Apex: lies below the chin-
 Contents
4 Submental Lymph Node (superficial fascia)
Drains: lower lip, gums, floor of mouth, tip of
tongue
b. Diagastric Triangle
 Boundries
Anterio-inferior: Anterior belly of digastric
Posterio-inferior: Posterior belly of Digastric &
Stylohyoid
Superiorly (base): Lower border of body of Mandible
Floor: Mylohyoid (anterior) & Hyoglossus muscle
(Posterior), part of middle constrictor muscle of
pharynx
Roof: skin, superficial fascia (Platysma, Cervical
branch of facial nerve, ascending branch of
anterior/transverse cutaneous nerve, deep fascia
splits to enclose submandibular gland
 Contents
Anterior part: submandibular salivary
gland, Facial artery & vein,
Submandibular Lymph nodes.
Hypoglossal nerve, Nerves & Vessels to
Mylohyoid Muscle, submental artery
Posterior part: Carotid sheath with
carotid arteries, Internal jugular vein,
Vagus nerve, Lower part of parotid
gland projects into triangle
c. Carotid triangle
 It lies behind the hyoid bone
Boundries
Anterio-Superiorly: Posterior belly of digastric &
stylohoid
Anterio-Inferiorly: Superior belly of Omohyoid
Posteriorly: Anterior border of sternocleidomastoid
Floor: Portion of thyrohyoid muscle, Hyoglossus,
middle & inferior constrictor muscle of pharynx
Roof: Skin, Superficial fascia (Platysma, Cervical
branch of facial nerve, transverse cutaneous
nerve, investing layer of deep cervical fascia
Floor of carotid triangle
 Contents:
Arteries: Carotid sheath with
dividing carotid artery into
internal & external carotid
artery (superior thyroid, lingual,
facial, ascending pharyngeal
and occipital branches)
Veins: internal jugular vein
( common facial vein,
pharyrgeal vein, lingual vein)
Nerves: Hypoglossal nerve,
Internal & external laryngeal
nerve, Accessory & vagus
nerves, spinal nerve,
Lymph nodes: part of chain of
deep cervical lymph nodes
Contents of carotid triangle
d. Muscular Triangle
 It lies below hyoid bone
 Boundaries
Anteriorly: Midline of neck (Hyoid bone to
sternum)
Posterio-Superiorly: Superior belly of omohyoid
Posterio-Inferiorly: Anterior border of
sternocleidomastoid
Floor (Contents): Sternohyoid & Sternothyroid,
Beneath the floor lies thyroid gland (Thyrohyoid)
, larynx , trachea & esophagus, Omohyoid
Posterior Triangle Of Neck
Boundaries
 Features:
Space on side of neck situated behind sternocleidomastoid
 Boundaries:
Posteriorly: Anterior border of trapezius muscle.
Anteriorly: Posterior border of sternocleidomastoid muscle
Inferiorly: Middle 1/3rd of clavicle
Apex: Lies on superior nuchal line where trapezius & sternocleidomastoid meet
Floor: Prevertebral layer of deep cervical fascia, covering following muscles:
1. Splenius capitis
2. Levator scapulae
3. Scalenus (Posterior,Middle,Anterior)
4. Semispinalis capitis
 Roof : Investing layer of deep
cervical fascia.
 Superficial fascia over posterior
triangle contains:
1. Platysma
2. External jugular & posterior
external jugular veins
3. Parts of supraclavicular, great
auricular, transverse cutaneous
& lesser occipital nerves
4. Unnamed arteries derived
from occipital, transverse
cervical & suprascapular
arteries.
5. Lymph vessels which pierce
deep fascia to end in
supraclavicular nodes.
External Jugular Vein
 It lies deep to platysma.
 It is formed by union of posterior auricular vein with posterior division of
retromandibular vein. It begins within lower part of parotid gland, crosses
sternocleidomastoid obliquely, pierces antero-inferior angle of roof of posterior triangle
& opens into subclavian vein.
Its tributaries are:
a. Posterior external jugular vein
b. Transverse cervical vein
c. Suprascapular vein
d. Anterior jugular vein
Oblique jugular vein connects external jugular vein with internal jugular vein across
middle 1/3rd of anterior border of sternocleidomastoid.
Posterior Triangle Of Neck
(Sub-divisions)
 Posterior triangle of neck is subdivided by
inferior belly of omohyoid muscle into :
1). Above: Large Occipital
2). Below: Small Supra-Clavicular triangle
1). Occipital Triangle
 Occipital triangle: larger division of posterior triangle, is bounded
Infront: by sternocleidomastoid
Behind: by Trapezius
Below: by inferior belly of omohyoid
Its Floor: is formed from above downward by splenius capitis, Levator
scapulae & scaleni medius & posterior.
Its covered :by skin, superficial & deep fascia and platysma below.
Roof: cutaneous nerves of cervical plexus, external jugular vein & platysma
muscle
2. Supra Clavicular Triangle
 Subclavian triangle (or supraclavicular triangle,
omoclavicular triangle): smaller division of posterior triangle
is bounded
Above: by inferior belly of omohyoid
Below: by clavicle
Base: posterior border of sternocleidomastoid
Contents
 A). Nerves & Plexuses:
OCCIPITAL TRIANGLE:
1). Spinal accessory nerve (Cranial Nerve XI)
2). Four cutaneous Branches of cervical plexus (Transverse cutaneous nerve,
Supraclavicular nerves, Great auricular nerve, Lesser occipital)
3). Muscular branches to levator scapulae (C3, C4), trapezius (C3, C4), Nerve to
rhomboid or dorsal scapular nerve (C5)
4). C5, C6 roots of brachial plexus
SUB-CLAVIAN TRIANGLE:
4).Nerves to serratus anterior (C5–C7), subclavius (C5, C6), Suprascapular (C5, C6)
5).Roots & trunks of Brachial Plexus
6).Phrenic Nerve (C3,4,5)
 B). Vessels:
1). Subclavian artery (3rd part) & Vein
2). Transverse cervical artery & Vein
3). Suprascapular artery & Vein
4). Terminal part of external jugular vein
5). Occipital artery
6). Lower part of external jugular vein
 C). Lymph Nodes
1). Occipital
2). Supraclavicular
D) Muscles:
1). Inferior belly of Omohyoid muscle
2). Anterior scalene
3). Middle scalene
4). Posterior scalene
5). Levator scapulae muscle
6). Splenius muscle
Clinical Relevance
Enlargement of
supraclavicular lymph nodes
 Most common swelling in posterior triangle is due to
enlargement of supraclavicular lymph nodes.
 While biopsy of lymph node, careful preserve
accessory nerve which may get entangled amongst
enlarged lymph nodes.
 Commonly enlarged in:
1. Tuberculosis,
2. Hodgkin’s disease
3. Malignant growths of breast, arm or chest.
 Block dissection of neck for malignant
diseases is removal of cervical lymph
nodes along with other structures involved
in growth.
 This procedure does not endanger those
nerves of posterior triangle which lie deep to
prevertebral fascia, i.e. brachial & cervical
plexuses and their muscular branches.
Compression of Subclavian Artery
 A cervical rib may compress second
part of subclavian artery. In these
cases, blood supply to upper limb
reaches via anastomoses around
scapula.
 Second part of subclavian artery may
get pressed by scalenus anterior
muscle, resulting in decreased blood
supply to upper limb.
If muscle is divided, effects are
abolished
Dysphagia lusoria
 Caused by compression
of oesophagus by an
abnormal subclavian
artery is called dysphagia
lusoria.
Aneurysms, AV fistulae or
arteriosclerotic occlusions
 Elective arterial surgery of common
carotid artery is done for aneurysms, AV
fistulae or arteriosclerotic occlusions.
 It is better to expose common carotid artery
in its upper part where it is superficial.
 While ligating artery, care should be taken
not to include vagus nerve or sympathetic
chain.
Muscles of Neck
Muscle Origin Insertion Nerve Supply Action
1 Platysma Deep fascia over
pectoralis major and
deltoid
Body of
mandible and
angle of mouth
Facial nerve
cervical branch
Depresses mandible &
angle of mouth
2 Sternocleidomastoid Manubrium sterni and
medial third of clavicle
Mastoid
process of
temporal bone
& occipital
bone
Spinal part of
accessory nerve &
C2, C3
Two muscles acting
together extend head &
flex neck; one muscle
rotates head to
opposite side
3 Digastric -
Posterior belly
Mastoid process of
temporal bone
Intermediate
tendon is held
to hyoid by
fascial sling
Facial nerve Depresses mandible or
elevates hyoid bone
Digastric-
Anterior belly
Body of mandible Nerve to mylohyoid
Muscle Origin Insertion Nerve Supply Action
4 Stylohyoid Styloid process Body of hyoid bone Facial nerve Elevates hyoid bone
5 Mylohyoid Mylohyoid line of body of
mandible
Body of hyoid bone &
fibrous raphe
Inferior alveolar
nerve
Elevates floor of mouth &
hyoid bone or depresses
mandible
6 Geniohyoid Inferior mental spine of
mandible
Body of hyoid bone 1st cervical
nerve
Elevates hyoid bone or
depresses mandible
7 Sternohyoid Manubrium sterni &
clavicle
Body of hyoid bone Ansa cervicalis;
C1, 2 & 3
Depresses hyoid bone
8 Sternothyroid Manubrium sterni Oblique line on lamina
of thyroid cartilage
Ansa cervicalis;
C1, 2, and 3
Depresses larynx
9 Thyrohyoid Oblique line on lamina of
thyroid cartilage
Lower border of body
of hyoid bone
1st cervical
nerve
Depresses hyoid bone or
elevates larynx
10 Inferior belly
Omohyoid
Upper margin of scapula
and suprascapular
ligament
Intermediate tendon is
held to clavicle and
first rib by fascial sling
Ansa cervicalis;
C1, 2, and 3
Depresses hyoid bone
Superior belly
Omohyoid
Lower border of body of
hyoid bone
Muscle Origin Insertion Nerve Supply Action
11 Scalenus
anterior
Transverse processes of
3rd, 4th, 5th, & 6th
cervical vertebrae
1st rib (Scalene
tubercle)
Anterior rami
C4, C5, C6
Cervical nerves
Elevates 1st rib; laterally
flexes & rotates cervical
part of vertebral column
12 Scalenus
medius
Transverse processes of
atlas & upper 5 cervical
vertebrae
Anterior rami of
lower cervical
nerves
13 Scalenus
posterior
(absent or
blended with
Scalenus
medius)
Transverse processes of
lower cervical vertebrae
2nd rib Elevates 2nd rib; laterally
flexes & rotates cervical
part of vertebral column
Thank You
Test?
Scalenus anterior
 Lateral part of Neck
Anteriorly: subclavian artery
Posteriorly: Phrenic nerve
 Relations:
Medially: Vertebral artery & vein, sympathetic trunk,thoracic duct (Left side)
Laterally: Emerging branch of cervical plexus, roots of brachial plexus, 3rd part of
subclavian artery
Anteriorly: Preverebral layer of deep cervical fascia, Clavicle, subclavius, Carotid
arteries,Vagus nerve, Internal Jugular vein,deep cervical lymph nodes,
sternocleidomastoid & omohyoid muscle. Lateral part of carotid sheath, transverse
cervical, suprascapular & ascending cervical arteries, subclavian vein. C3 to C5 spinal
roots which form phrenic nerve right on anterior surface of scalenus anterior.
Posteriorly: suprapleural membrane, cervical pleura, roots of brachial plexus &
subclavian artery (2nd part).
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  • 1. Triangles of Neck Dr. Rabia Inam Gandapore Assistant Professor Head of Department Anatomy (Dentistry-BKCD) B.D.S (SBDC), M.Phil. Anatomy (KMU), Dip. Implant (Sharjah, Bangkok, ACHERS) , CHPE (KMU),CHR (KMU), Dip. Arts (Florence, Italy)
  • 2. Teaching Methodology  LGF (Long Group Format)  SGF (Short Group Format)  LGD (Long Group Discussion, Interactive discussion with the use of models or diagrams)  SGD (Short Group)  SDL (Self-Directed Learning)  DSL (Directed-Self Learning)  PBL (Problem- Based Learning)  Online Teaching Method  Role Play  Demonstrations  Laboratory  Museum  Library (Computed Assisted Learning or E-Learning)  Assignments  Video tutorial method
  • 3. Goal/Aim (main objective) To help/facilitate/augment the students about the:  Describe superficial fascia & deep fascia.  Enlist subdivisions of anterior triangle of neck a. Submental Triangle b. Digastric triangle c. Carotid Triangle d. Muscular Triangle  Describe boundaries & content of anterior triangle of neck.  Describe boundaries & content of carotid triangle of neck.  Describe boundaries & content of muscular triangle  Describe attachments, nerve supply & actions of infrahyoid muscles.  Enumerate clinical problems related to anterior neck region.  Describe boundaries, divisions & contents of posterior triangle.  Discuss swelling of supraclavicular lymph nodes.
  • 4. Specific Learning Objectives (cognitive) At the end of the lecture the student will able to:  Describe superficial fascia & deep fascia.  Enlist subdivisions of anterior triangle of neck a. Submental Triangle b. Digastric triangle c. Carotid Triangle d. Muscular Triangle  Describe boundaries & content of anterior triangle of neck.  Describe boundaries & content of carotid triangle of neck.  Describe boundaries & content of muscular triangle  Describe attachments, nerve supply & actions of infrahyoid muscles.  Enumerate clinical problems related to anterior neck region.  Describe boundaries, divisions & contents of posterior triangle.  Discuss swelling of supraclavicular lymph nodes.
  • 5. Psychomotor Objective: (Guided response)  A student to draw labelled diagram of the triangles of neck
  • 6. Affective domain  To be able to display a good code of conduct and moral values in the class.  To cooperate with the teacher and in groups with the colleagues.  To demonstrate a responsible behavior in the class and be punctual, regular, attentive and on time in the class.  To be able to perform well in the class under the guidance and supervision of the teacher.  Study the topic before entering the class.  Discuss among colleagues the topic under discussion in SGDs.  Participate in group activities and museum classes and follow the rules.  Volunteer to participate in psychomotor activities.  Listen to the teacher's instructions carefully and follow the guidelines.  Ask questions in the class by raising hand and avoid creating a disturbance.  To be able to submit all assignments on time and get your sketch logbooks checked.
  • 7. Lesson contents Clinical chair side question: Students will be asked if they know what is the function of triangles of neck Outline:  Activity 1 The facilitator will explain the student's Triangles of Neck in detail  Activity 2 The facilitator will ask the students to locate triangles of Neck on Model  Activity 3 The facilitator will ask the students a few Multiple Choice Questions related to it with flashcards.
  • 8. Recommendations  Students assessment: MCQs, Flashcards, Diagrams labeling.  Learning resources: Langman’s T.W. Sadler, Laiq Hussain Siddiqui, Snell Clinical Anatomy, Netter’s Atlas, BD Chaurasia’s Human anatomy, Internet sources links.
  • 9.
  • 10.
  • 11. Introduction  Side of neck presents a quadrilateral outline. Its limited:  Above: by lower border of body of mandible & an imaginary line drawn from angle of mandible to mastoid process.  Below: limited by upper border of clavicle.  Medially: by midline of neck.  Posteriorly: by anterior border of Trapezius muscle .
  • 12. Sternocleidomastoid & Trapezius Muscles  Large superficial muscles of neck.  Both of them are supplied by spinal root of accessory nerve.
  • 13.
  • 14.
  • 15.
  • 16. Sternocleidomastoid  This quadrilateral space is divided by Sternocleidomastoid muscle into 2 triangles .  It passes obliquely upwards and backwards from its site of origin at clavicle & sternum to its point of insertion on the mastoid process & occipital bone .  The triangle in front of this muscle is the anterior triangle & behind it is the posterior triangle .
  • 17. Sternocleidomastoid  Origin: 1. Sternal head arises from superolateral part of front of manubrium sterni. 2. Clavicular head arises from medial1/3rd of superior surface of clavicle.  Between two heads, there is a small triangular depression of lesser supraclavicular fossa, overlying internal jugular vein
  • 18.
  • 19.  Insertion: 1. By a thick tendon into lateral surface of mastoid process, from its tip to superior border. 2. By a thin aponeurosis into lateral half of superior nuchal line of occipital bone.  Nerve Supply: 1. Spinal accessory nerve (motor supply). It passes through muscle. 2. Branches from ventral rami of C2 & C3 are proprioceptive.  Blood Supply Arterial supply: one branch each from superior thyroid artery & suprascapular artery and, two branches from occipital artery supply big muscle. Veins: follow arteries
  • 20.
  • 21.  Actions: 1. Unilateral contracts: a. It turns chin to opposite side. b. It can also tilt head towards shoulder of same side. 2. Bilateral contract together: a. They draw the head forwards, as in eating & in lifting head from a pillow. b. With longus colli, they flex the neck against resistance. c. It also helps in forced inspiration
  • 22.  Relations: sternocleidomastoid is enclosed in investing layer of deep cervical fascia & is pierced by accessory nerve & four sternocleidomastoid arteries. It has following relations.  Superficial: 1. Skin 2. Superficial fascia & Superficial lamina of deep cervical fascia 3. Platysma 4. External jugular vein & superficial cervical lymph nodes. 5. Cervical Plexus: Great auricular, Transverse or anterior cutaneous, Medial supraclavicular nerves & Lesser occipital nerve 6. Parotid gland overlaps muscle.  Deep: 1 Bones and joints: Above: Mastoid process, Below: Sternoclavicular joint 2 Carotid sheath 3 Muscles: Sternohyoid, Sternothyroid, Omohyoid, 3 scalene, Levator scapulae, Splenius capitis, Longissimus capitis, Posterior belly of digastric.
  • 23.
  • 24.  4. Arteries: Common carotid (Internal carotid & External carotid), Sternocleidomastoid arteries (2 from occipital artery, 1 from superior thyroid, 1 from suprascapular), Occipital, Subclavian, Suprascapular & Transverse cervical 5. Veins: Internal jugular , Anterior jugular, Facial, Lingual 6. Nerves: Vagus, Parts of IX (GP), XI (SA), XII (HG), Cervical plexus (Ansa cervicalis & Phrenic), Upper part of brachial plexus,, 7. Lymph nodes: superficial & deep cervical .
  • 25.
  • 26. Clinical Relevance  Sucide attempts fail as it’s a thick muscle protecting the underlying structures. And only succeed if greater part of sternocleidomastoid muscle & larynx have been severed
  • 27. Torticollis  Spasmodic Torticollis (Twisted-Neck Collar): deformity in which head is bent to one side & chin points to other side.  Cause: spasm or contracture of muscles supplied by spinal accessory nerve, these being sternocleidomastoid & trapezius.  Many Types of torticollis but common types are: a. Rheumatic torticollis: due to exposure to cold or draught. b. Reflex torticollis: due to inflamed or suppurating cervical lymph nodes which irritate spinal accessory nerve.
  • 29. Boundaries  Posteriorly (Lateral) By: Ant border of Sternocleidomastoid Anteriorly (Medial) By: Midline of Neck Superiorly By: Lower Margin of body of mandible  Coverings: Skin, Superficial Fascia, Platysma & Investing layer of deep fascia running across the triangle in this coverings are cervical branch of facial nerve & transverse cutaneous nerve.  Sub- divided into smaller triangles by:  Anterior & Posterior bellies of digastric muscle  Superior belly of omohyoid muscle
  • 30.
  • 31. a. Submental Triangle  Median triangle  Boundries: Anteriorly: Midline of the neck Laterally: Anterior belly of digastric Inferiorly (base): Body of hyoid bone Floor: Mylohyoid muscle & median raphe attached Apex: lies below the chin-  Contents 4 Submental Lymph Node (superficial fascia) Drains: lower lip, gums, floor of mouth, tip of tongue
  • 32.
  • 33.
  • 34.
  • 35.
  • 36. b. Diagastric Triangle  Boundries Anterio-inferior: Anterior belly of digastric Posterio-inferior: Posterior belly of Digastric & Stylohyoid Superiorly (base): Lower border of body of Mandible Floor: Mylohyoid (anterior) & Hyoglossus muscle (Posterior), part of middle constrictor muscle of pharynx Roof: skin, superficial fascia (Platysma, Cervical branch of facial nerve, ascending branch of anterior/transverse cutaneous nerve, deep fascia splits to enclose submandibular gland
  • 37.
  • 38.
  • 39.
  • 40.
  • 41.  Contents Anterior part: submandibular salivary gland, Facial artery & vein, Submandibular Lymph nodes. Hypoglossal nerve, Nerves & Vessels to Mylohyoid Muscle, submental artery Posterior part: Carotid sheath with carotid arteries, Internal jugular vein, Vagus nerve, Lower part of parotid gland projects into triangle
  • 42.
  • 43. c. Carotid triangle  It lies behind the hyoid bone Boundries Anterio-Superiorly: Posterior belly of digastric & stylohoid Anterio-Inferiorly: Superior belly of Omohyoid Posteriorly: Anterior border of sternocleidomastoid Floor: Portion of thyrohyoid muscle, Hyoglossus, middle & inferior constrictor muscle of pharynx Roof: Skin, Superficial fascia (Platysma, Cervical branch of facial nerve, transverse cutaneous nerve, investing layer of deep cervical fascia
  • 44.
  • 45.
  • 46. Floor of carotid triangle
  • 47.  Contents: Arteries: Carotid sheath with dividing carotid artery into internal & external carotid artery (superior thyroid, lingual, facial, ascending pharyngeal and occipital branches) Veins: internal jugular vein ( common facial vein, pharyrgeal vein, lingual vein) Nerves: Hypoglossal nerve, Internal & external laryngeal nerve, Accessory & vagus nerves, spinal nerve, Lymph nodes: part of chain of deep cervical lymph nodes Contents of carotid triangle
  • 48. d. Muscular Triangle  It lies below hyoid bone  Boundaries Anteriorly: Midline of neck (Hyoid bone to sternum) Posterio-Superiorly: Superior belly of omohyoid Posterio-Inferiorly: Anterior border of sternocleidomastoid Floor (Contents): Sternohyoid & Sternothyroid, Beneath the floor lies thyroid gland (Thyrohyoid) , larynx , trachea & esophagus, Omohyoid
  • 49.
  • 50.
  • 52. Boundaries  Features: Space on side of neck situated behind sternocleidomastoid  Boundaries: Posteriorly: Anterior border of trapezius muscle. Anteriorly: Posterior border of sternocleidomastoid muscle Inferiorly: Middle 1/3rd of clavicle Apex: Lies on superior nuchal line where trapezius & sternocleidomastoid meet Floor: Prevertebral layer of deep cervical fascia, covering following muscles: 1. Splenius capitis 2. Levator scapulae 3. Scalenus (Posterior,Middle,Anterior) 4. Semispinalis capitis
  • 53.
  • 54.
  • 55.  Roof : Investing layer of deep cervical fascia.  Superficial fascia over posterior triangle contains: 1. Platysma 2. External jugular & posterior external jugular veins 3. Parts of supraclavicular, great auricular, transverse cutaneous & lesser occipital nerves 4. Unnamed arteries derived from occipital, transverse cervical & suprascapular arteries. 5. Lymph vessels which pierce deep fascia to end in supraclavicular nodes.
  • 56.
  • 57.
  • 58. External Jugular Vein  It lies deep to platysma.  It is formed by union of posterior auricular vein with posterior division of retromandibular vein. It begins within lower part of parotid gland, crosses sternocleidomastoid obliquely, pierces antero-inferior angle of roof of posterior triangle & opens into subclavian vein. Its tributaries are: a. Posterior external jugular vein b. Transverse cervical vein c. Suprascapular vein d. Anterior jugular vein Oblique jugular vein connects external jugular vein with internal jugular vein across middle 1/3rd of anterior border of sternocleidomastoid.
  • 59.
  • 60.
  • 61. Posterior Triangle Of Neck (Sub-divisions)  Posterior triangle of neck is subdivided by inferior belly of omohyoid muscle into : 1). Above: Large Occipital 2). Below: Small Supra-Clavicular triangle
  • 62. 1). Occipital Triangle  Occipital triangle: larger division of posterior triangle, is bounded Infront: by sternocleidomastoid Behind: by Trapezius Below: by inferior belly of omohyoid Its Floor: is formed from above downward by splenius capitis, Levator scapulae & scaleni medius & posterior. Its covered :by skin, superficial & deep fascia and platysma below. Roof: cutaneous nerves of cervical plexus, external jugular vein & platysma muscle
  • 63.
  • 64. 2. Supra Clavicular Triangle  Subclavian triangle (or supraclavicular triangle, omoclavicular triangle): smaller division of posterior triangle is bounded Above: by inferior belly of omohyoid Below: by clavicle Base: posterior border of sternocleidomastoid
  • 65. Contents  A). Nerves & Plexuses: OCCIPITAL TRIANGLE: 1). Spinal accessory nerve (Cranial Nerve XI) 2). Four cutaneous Branches of cervical plexus (Transverse cutaneous nerve, Supraclavicular nerves, Great auricular nerve, Lesser occipital) 3). Muscular branches to levator scapulae (C3, C4), trapezius (C3, C4), Nerve to rhomboid or dorsal scapular nerve (C5) 4). C5, C6 roots of brachial plexus SUB-CLAVIAN TRIANGLE: 4).Nerves to serratus anterior (C5–C7), subclavius (C5, C6), Suprascapular (C5, C6) 5).Roots & trunks of Brachial Plexus 6).Phrenic Nerve (C3,4,5)
  • 66.  B). Vessels: 1). Subclavian artery (3rd part) & Vein 2). Transverse cervical artery & Vein 3). Suprascapular artery & Vein 4). Terminal part of external jugular vein 5). Occipital artery 6). Lower part of external jugular vein  C). Lymph Nodes 1). Occipital 2). Supraclavicular D) Muscles: 1). Inferior belly of Omohyoid muscle 2). Anterior scalene 3). Middle scalene 4). Posterior scalene 5). Levator scapulae muscle 6). Splenius muscle
  • 67.
  • 68.
  • 69.
  • 70.
  • 71.
  • 72.
  • 73.
  • 75. Enlargement of supraclavicular lymph nodes  Most common swelling in posterior triangle is due to enlargement of supraclavicular lymph nodes.  While biopsy of lymph node, careful preserve accessory nerve which may get entangled amongst enlarged lymph nodes.  Commonly enlarged in: 1. Tuberculosis, 2. Hodgkin’s disease 3. Malignant growths of breast, arm or chest.
  • 76.  Block dissection of neck for malignant diseases is removal of cervical lymph nodes along with other structures involved in growth.  This procedure does not endanger those nerves of posterior triangle which lie deep to prevertebral fascia, i.e. brachial & cervical plexuses and their muscular branches.
  • 77. Compression of Subclavian Artery  A cervical rib may compress second part of subclavian artery. In these cases, blood supply to upper limb reaches via anastomoses around scapula.  Second part of subclavian artery may get pressed by scalenus anterior muscle, resulting in decreased blood supply to upper limb. If muscle is divided, effects are abolished
  • 78. Dysphagia lusoria  Caused by compression of oesophagus by an abnormal subclavian artery is called dysphagia lusoria.
  • 79. Aneurysms, AV fistulae or arteriosclerotic occlusions  Elective arterial surgery of common carotid artery is done for aneurysms, AV fistulae or arteriosclerotic occlusions.  It is better to expose common carotid artery in its upper part where it is superficial.  While ligating artery, care should be taken not to include vagus nerve or sympathetic chain.
  • 81. Muscle Origin Insertion Nerve Supply Action 1 Platysma Deep fascia over pectoralis major and deltoid Body of mandible and angle of mouth Facial nerve cervical branch Depresses mandible & angle of mouth 2 Sternocleidomastoid Manubrium sterni and medial third of clavicle Mastoid process of temporal bone & occipital bone Spinal part of accessory nerve & C2, C3 Two muscles acting together extend head & flex neck; one muscle rotates head to opposite side 3 Digastric - Posterior belly Mastoid process of temporal bone Intermediate tendon is held to hyoid by fascial sling Facial nerve Depresses mandible or elevates hyoid bone Digastric- Anterior belly Body of mandible Nerve to mylohyoid
  • 82.
  • 83. Muscle Origin Insertion Nerve Supply Action 4 Stylohyoid Styloid process Body of hyoid bone Facial nerve Elevates hyoid bone 5 Mylohyoid Mylohyoid line of body of mandible Body of hyoid bone & fibrous raphe Inferior alveolar nerve Elevates floor of mouth & hyoid bone or depresses mandible 6 Geniohyoid Inferior mental spine of mandible Body of hyoid bone 1st cervical nerve Elevates hyoid bone or depresses mandible 7 Sternohyoid Manubrium sterni & clavicle Body of hyoid bone Ansa cervicalis; C1, 2 & 3 Depresses hyoid bone 8 Sternothyroid Manubrium sterni Oblique line on lamina of thyroid cartilage Ansa cervicalis; C1, 2, and 3 Depresses larynx 9 Thyrohyoid Oblique line on lamina of thyroid cartilage Lower border of body of hyoid bone 1st cervical nerve Depresses hyoid bone or elevates larynx 10 Inferior belly Omohyoid Upper margin of scapula and suprascapular ligament Intermediate tendon is held to clavicle and first rib by fascial sling Ansa cervicalis; C1, 2, and 3 Depresses hyoid bone Superior belly Omohyoid Lower border of body of hyoid bone
  • 84.
  • 85.
  • 86.
  • 87. Muscle Origin Insertion Nerve Supply Action 11 Scalenus anterior Transverse processes of 3rd, 4th, 5th, & 6th cervical vertebrae 1st rib (Scalene tubercle) Anterior rami C4, C5, C6 Cervical nerves Elevates 1st rib; laterally flexes & rotates cervical part of vertebral column 12 Scalenus medius Transverse processes of atlas & upper 5 cervical vertebrae Anterior rami of lower cervical nerves 13 Scalenus posterior (absent or blended with Scalenus medius) Transverse processes of lower cervical vertebrae 2nd rib Elevates 2nd rib; laterally flexes & rotates cervical part of vertebral column
  • 88.
  • 89.
  • 90.
  • 92. Test?
  • 93.
  • 94. Scalenus anterior  Lateral part of Neck Anteriorly: subclavian artery Posteriorly: Phrenic nerve  Relations: Medially: Vertebral artery & vein, sympathetic trunk,thoracic duct (Left side) Laterally: Emerging branch of cervical plexus, roots of brachial plexus, 3rd part of subclavian artery Anteriorly: Preverebral layer of deep cervical fascia, Clavicle, subclavius, Carotid arteries,Vagus nerve, Internal Jugular vein,deep cervical lymph nodes, sternocleidomastoid & omohyoid muscle. Lateral part of carotid sheath, transverse cervical, suprascapular & ascending cervical arteries, subclavian vein. C3 to C5 spinal roots which form phrenic nerve right on anterior surface of scalenus anterior. Posteriorly: suprapleural membrane, cervical pleura, roots of brachial plexus & subclavian artery (2nd part).