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THE NECK II

Dr. Elinor Spring-Mills

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LECTURE CONTENTS

ARTERIES of the HEAD and NECK

LYMPH NODES and LYMPHATIC VESSELS of

the HEAD and NECK

CERVICAL SYMPATHETIC CHAINS and

GANGLIA

HORNERS SYNDROME

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VESSELS OF THE FACE AND NECK

3 MAJOR VEINS

ANTERIOR, EXTERNAL AND INTERNAL JUGULAR VEINS

3 MAJOR ARTERIES

SUBCLAVIAN, VERTEBRAL, CAROTIDS ( COMMON, INTERNAL AND EXTERNAL )

WELL DEVELOPED LYMPHATIC SYSTEM

******

FUNCTIONAL IMPLICATIONS OF ARCHITECTURAL PATTERN

Helps to:

integrate distant parts of the body

maintain homeostasis

PRACTICAL IMPLICATIONS

KNOWLEDGE OF PATTERNS IS IMPORTANT FOR

detecting pulses

palpating diseased lymph nodes

performing surgical/invasive procedures on the face and neck

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1 Internal carotidExternal

carotid2

3

4

The neck and head receive most arterial blood from 4 sources,the : internal and external

carotid, vertebral and subclavian arteries.

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Red = External carotid

Black = Internal Carotid

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3

RIGHT : Brachiocephalic Trunk ( Right Common Carotid and Right Subclavian)

LEFT: Left Common Carotid, Left Subclavian

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Arrows point to the

3 arteries from the

arch of the aorta.

Note the right-left

differences.

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Observe the relationship of the great veins to the arch of the aorta and the manubrium.

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C 6

T 2 at

jugular

notch

T 4,5

STERNAL ANGLE

VERTEBRAL LEVELS

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The common carotid artery gives rise to the external and internal carotid arteries, while the

subclavian artery gives rise to the vertebral artery, thyrocervical and costocervical trunks.

The INTERNAL CAROTID ARTERYINTERNAL CAROTID ARTERY runs in theneck but has NO branches in the neck. It

supplies primarily the brain and the orbit of theeye.

The VERTEBRAL ARTERYVERTEBRAL ARTERY supplies mainly thebrain and the spinal cord.

The SUBCLAVIAN ARTERYSUBCLAVIAN ARTERY suppliesstructures deep in the neck and the viscerabelow the middle of the thyroid.

The EXTERNAL CAROTID ARTERYEXTERNAL CAROTID ARTERY suppliesessentially all other portions of the head andneck.

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COMMON CAROTID ARTERIES

Differ in origin and length on the right and left sides of

the body.

Travel within the carotid sheath parallel and medial to

the internal jugular vein and vagus nerve.

Have no branches.

Bifurcate at upper border of the thyroid cartilage (C 4)

into internal and external branches.

R. Common

carotid

L. Common

carotid

Right side of body

R.

Brachiocephalic

Trunk

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Right common carotid

artery

Left

common

carotid

artery

Brachiocephalic Trunk

NOTE right-left

differences in common

carotid arteries.

COLLATERAL CIRCULATION: after ligature of one common carotid artery, circulation can still occur

between the two sides of the head and neck because there are many important cross connections between

other vessels on the right and the left as shown on this and the next slide.

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COLLATERAL CIRCULATION

Occurs when blood from one major vessel is

diverted into the branches of another majorblood vessel through small vessels that

connect the two.

In some cases, the blood flows in a reverse

direction.

The amount and success of collateralcirculation depends upon the number and

size of the connecting vessels, the distribution

and extent of the injury or disease.

Stenosis/occlusion of a carotid artery is

involved in many strokes ( brain injurycaused by vascular disorders).

The bifurcation of the common carotid artery

into external and internal carotid arteries is

the most common site of atherosclerosis

within the carotid system of blood vessels.As indicated on the accompanying

illustration, if a major artery is occluded

slowly over time, the chances are good that

the collateral connections will effectively re-

route the blood.

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Know the types of

anastomoses

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EC

ST

M

At its origin, the external carotid artery (EC) is more superficial and nearer the midlinethan theinternal carotid artery. It decreases in size as it ascends and eventually passes behind the neck of

the mandible into the parotid gland. Its terminal branches are the superficial temporal (ST) and

maxillary arteries (M).N.B. it is impossible to see all the branches of the EC until portions of the mandible have beenremoved or reflected as is the case in this drawing

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Eight major branches usually arise in the following order

from the external carotid artery

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1

2 3

45

1. Superior Thyroid

2. Ascending

Pharyngeal

3. Lingual

4. Facial5. Occipital

6. Posterior

Auricular

7. SuperficialTemporal

8. Maxillary

67

8

Posterior

belly of

Digastric

Anterior belly,

Omohyoid

See the ancient Pharaoh looking for old posts and signs to Memphis.

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Facial

Superior Thyroid

Occipital

Posterior Auricular

Superficial Temporal

SCM

PG

ramus

angle

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HYPOGLOSSAL

NERVE

OCCIPITAL

ARTERY

LINGUAL ARTERY

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These two figures illustrate variations in the branching of the external carotid.

REMEMBER

Arteries are named for where they end up;

NOT for where they originate !

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Use this slide to test yourself.

Answers appear on next slide.

1

2

3

4 5

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Maxillary (3)

facial (2)

superior thyroid

(1)

ascending pharyngeal

(5)

Occipital

lingual

superficial temporalpost. Auricular(4)

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ORIGIN

Right : from brachiocephalic trunk

Left : from arch of aorta

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Anterior scalene

1st

part

First rib

Phrenic nerve

Brachial

plexus

SUBCLAVIANARTERIES

PARTS

1ST : origin to medial border of the anterior

scalene muscle

2nd : behind the anterior scalene muscle

3rd : lateral border of anterior scalene muscleto lateral border of first rib

REMEMBER

For the most part, the SUCLAVIAN

ARTERIES supply structures deep in the

neck and the viscera below the middle of the

thyroid gland.

SUBCLAVIAN ARTERY

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SUBCLAVIAN ARTERY

BRANCHES FROM 1ST PART

Vertebral Artery (VA) enters foramen transversarium of the 6th cervical vertebra and

runs to inferior surface of skull in foramina of the other upper

cervical vertebrae.

Thyrocervical Trunk (TT) gives rise to the inferior thyroid, transverse cervical and

suprascapular arteries (see next slide).

Internal Thoracic Artery (IT)

BRANCHES FROM 2ND PART

Costocervical Trunk (CT)arises from first part of subclavian on the left and second part of

the subclavian on the right.

The supreme intercostal artery, deep cervical artery and the

descending/dorsal scapula artery are three of its major branches

(see subsequent slides).

3rd PART

In 50 % of the population, it gives rise to thedescending/dorsal scapula artery.

After it passes the outer border of the 1st rib, it is renamed the

axillary artery.

VA

TTCT

IT

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FORAMEN TRANSVERSARIUM

The foramen transversarium transmits the vertebral artery, which is usually the first

branch of the subclavian artery.

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Arrows pointto vertebral

artery

Basilar artery

Anterior Posterior

Inside the cranium, theright vertebral artery joins the left vertebral artery to form the basilar

artery which participates in the formation of the circle of Willis.

Remember : vertebral arteries supply brain and spinal cord

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12

3

4

Subclavian artery

THYROCERVICAL TRUNK

1. SUPRASCAPULAR

2. TRANSVERSE CERVICAL

3. INFERIOR THYROID

4. ASCENDING CERVICAL from inferior thyroid

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Anterior scalene

First rib

Phrenic nerve

Brachial

plexus

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Deep Cervical

Supreme/highest

Intercostal

COSTOCERVICAL TRUNK

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IMPORTANT ANASTOMOTIC CONNECTIONS

Inferior Thyroid Artery (from thyrocervical trunk)-------- Superior Thyroid Artery(from external carotid) Vertebral ( from subclavian )------------------------------------ Occipital (from external carotid) Ascending Cervical (from inferior thyroid) ----------------- Occipital (from externalcarotid ) Ascending Cervical --------------------------------------------- Ascending Pharyngeal(from external carotid) Ascending Cervical--------------------------------------------- Vertebral (fromsubclavian) Deep Cervical (from costocervical trunk)--------------------- Descending branches ofOccipital (from external carotid) Deep Cervical-------------------------------------------------------Vertebral (fromsubclavian)

When the common carotid, external carotid or the subclavian artery is ligated ( or blocked ), the descendingbranches of the occipital artery provide the most collateral circulation through connections to the vertebral ,ascending and deep cervical arteries.

BLOOD SUPPLY TO

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BLOOD SUPPLY TO

THE

PARATHYROIDSfrom

external carotids and thyrocervical trunks

INFERIOR

THYROID

ARTERY

SUPERIOR

THYROID

ARTERY

LLEFT

SUBCLAVIAN

ARTERY

NOTE COMPLEXITY OF THIS AREA

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KNOW THESE

Important

anastomotic

connections

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There are many lymph nodes ( 300 +) in the head and neck. Some are very large. Others are nearly

microscopic. Since lymph nodes act as filters for particulate matter, infectious organisms and tumor

cells, they are palpated during most physical exams. An enlarged node often indicates an infection or

disease in an area that drains into it.

There are basically two types of nodessuperficial and deep

in this region of the body. Eventuallyall lymph from the head and neck is thought to drain into the deep cervical lymph nodes along the

carotid sheath.

You should know where the major groups of lymph nodes are located and how to palpate them.

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Lymphatic Drainage of the Superficial Tissues of the Head and Neck.

Most of these lymph nodes are located near thejunction of the head and neck.

Many nodes are located in the posterior triangle of the neck along the external jugular vein.

In the anterior triangleof the neck, many nodes are located along the anterior jugular vein.

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Lymph nodes also are numerous around glands in the neck.

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REMEMBER

Essentially all efferent lymphatic vessels from

the superficial lymph nodes drain into the deepcervical lymph nodes.

N.B. There are NO lymph nodes on the upper

regions of the head !

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The deep cervical lymph nodes form a deep vertical chain along the carotid sheath.

Often they are subdivided into a superior and inferior group.

The superior group lies under the sternocleidomastoid muscle, along the XI

cranial nerve and internal jugular vein.

The inferior group lies along the inferior,posterior border of the

sternocleidomastoid muscle, close to the subclavian vein.

BLUE LINE

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INFERIOR GROUP OF

DEEP CERVICALLYMPH NODES

( lying along posterior

border of

sternocleidomastoid

muscle, close to

subclavian vein)

Receive lymph from

Dorsum of scalp

Dorsum of Superficial

neck

Superficial pectoral region

Part of superficial arm

SHOWS DIVISION OF

DEEP SUPERIOR AND

INFERIOR GROUPS OFNODES

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Use these images to acquaint yourself with thegeneral location of lymph vessels and nodes in the

neck. Only the bad children will have to identify all

300 !!!

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At the Root of the Neck

on the right, the jugular lymph trunk/right lymphatic duct terminates at the junction of the

internal jugular and subclavian veins

on the left, the jugular lymph duct terminates in the thoracic duct.

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WHEN YOUR PATIENT HAS ENLARGEDLYMPH NODES

Inspect, Palpate

Tender nodes often are inflamed or infected.

Firm, fixed, hard nodes often are associated with a tumor.

Ask

Have nodes been enlarged for a few days ? Months ?

( The longer the nodes have been present, and the more elderly the individual,

the more likely it is that the enlarged nodes are associated with a tumor.)

REVIEW

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THE POSITION OF CERVICAL

LYMPH NODES

TROUBLESHOOTING ENLARGED LYMPH NODES *

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Divide Neck into Three Regions

Inferior, Lower Third Middle Third Upper Third

Disease below clavicle usually THYROID usually Head or

Upper Neck

On Left : an enlarged 1. Submental nodes: often

Virchows node( above middle third floor of mouth; lower lip and/or

of clavicle, near termination teeth.

of thoracic duct), often indicates 2. Submandibular nodes: oftena tumor below diaphragm, sinuses; upper lip;

anterior

Lower Esophagus or Stomach. tongue especially

Lateral lower third

Breast; sometimes stomach

* List is not all inclusive.

KNOW THIS

NECK MASSES

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REMEMBER

Lumps and bumps in the neck are not

always lymph nodes.

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NECK MASSES ASSOCIATED

WITH DISEASES OF THE

THYROID

SENTINEL NODES

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Usually are the first node or nodes to which infections or cancer cells spread

from the primary site.

If a sentinel node does not contain cancer cells, it is often unnecessary to

remove other regional nodes. Hence, there will be fewer complicationsassociated with the biopsy.

Evaluation of cervical lymph nodes is essential for determining the nature and

etiology of many different diseases, those that originate in the head and neck as

well as diseases that have originated at distant sites such as: lymphoma ( any

neoplastic disorder of lymphoid tissue), HIV, sarcoidosis ( a chronic,

progressive, systemic granulomatous reticulosis of unknown origin), etc.

When multiple cervical lymph nodes are enlarged because of a primary tumor

in the head or neck, the lymph node levels and the size of the nodes are

determined to evaluate the extent of tumor spread. The data is then used to

select the best treatment and it often provides a reliable guide to prognosis.

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SWELLING

ASSOCIATED WITH

PAROTID GLANDTUMOR

CERVICAL SYMPATHETIC

TRUNK/CHAIN AND GANGLIA

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The cervical sympathetic chain and ganglia are

located anterior to the transverse processes of

the cervical vertebra, often very close to the

posterior surface of the carotid sheath but

medial to the Vagus. The chain runs from thebase of the skull to the neck of the first rib.

COMPONENTS

3 GANGLIA ON EACH SIDE

CONNECTING TRUNKS FROM THORACIC

SYMPATHETIC CHAINS

PREGANGLIONIC FIBERS ( that ascend from T 1- ?6)

POSTGANGLIONIC CELL BODIES AND FIBERS

(called gray rami communicantes)

THERE ARE NO WHITE RAMI

COMMUNICANTES ON THE CERVICAL

SYMPATHETIC TRUNKS !!!!!

TRUNK/CHAIN AND GANGLIA

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SUPERIOR CERVICAL GANGLION (SCG)

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( )

Largest one

(probably arose from the fusion of the upper four ganglia associated with cervicalnerves 1 4)

1. Usually found between the internal carotid artery and the longus

capitis muscle at the level of the 2nd 3rd cervical vertebrae.

2. The inferior pole of the ganglion often is encountered at the level of

the bifurcation of the common carotid.

3. Preganglionic fibers usually ascend from T 1 4 levels of the spinal

cord to synapse in the SCG

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SCG

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MIDDLE CERVICAL GANGLION

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SMALLEST GANGLION

OFTEN MISSING

Usually found anterior to the transverse processes of C 6,7 at the level of the cricoid

cartilage and the cranial bend of the inferior thyroid artery.

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INFERIOR CERVICAL

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GANGLIONLies between base of transverse process of C 7 and neck of the first

rib, close to the origin of the vertebral artery.

About 50 % of the time, it fuses with the first thoracic ganglion to

form the large,cervicothoracic or stellate ganglion

Also note that two or more nerve bundles from the sympathetic

trunk usually connect the middle and inferior cervical ganglia.

The more anterior bundle, that crosses ventral to the first part of

the subclavian artery and turns upward behind it, is called theansa

subclavia.

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HORNERS SYNDROME

When the cervical sympathetics above T1 or C8 are severed or damaged, sympathetic control of

various functions in the head, neck and upper extremity on the side of the injury are lost or

i i d d diti k H d ll

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impaired and a condition known as Horners syndrome usually ensues.

SYMPTOMS

includesome or allof the following:

lack of sweating (anhydrosis) ;

constriction of the pupil (miosis) caused by paralysis of the dilator pupillae muscle; ptosis/drooping of the upper eyelid from paralysis of the smooth muscle in the levator palpebrae superioris;

enopthalmos, the sinking of the eyeball into the orbital cavity, from paralysis of the smooth muscle in the

orbitalis muscle in the floor of the orbit;

flushing of the skin (unable to constrict the blood vessels), etc.

Common causes of this Syndrome

lesions of the brainstem or cervical part of the spinal cord; traction on the stellate ganglion by a

cervical rib; cancerous involvement of a ganglion, etc.

When the damage occurs bilaterally, there is no acceleration of the heart rate because the

superior, middle and inferior cardiac nerves are not be functioning.

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Horners syndrome is illustrated above. The affected side of the face is not sweating,

has a droopy upper eyelid and a constricted pupil.

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A CERVICAL RIB is an extra or supernumerary rib. They occur in 1 3 % of the population and usuallyarticulate with the 7th cervical vertebra. If they compress the C8 and T1 nerves (which form the

inferior/lower trunk of the brachial plexus) the individual may experience numbness and tingling along the

medial border of the forearm. When they compress the ganglia associated with these nerves Horners

syndrome is likely. And, when the rib compresses the subclavian artery, there may be so-called ischemic

muscle pain in the upper extremity on the affected side.

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Paresis : partial paralysis

Pancoast tumor: of apex of lung, extending upward

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SOURCES OF ILLUSTRATIONS

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SOURCE Frame(s)

Netter Presenter

1,3,4,6,8,10,11,12,113,15,17,18,19,

22,23,26,27,28-30,31,35,41,42,50,54,64

Moore 3

Pansky 6,23,32,34,39

Rosse et al 7,20,21,23,51,53

Grants 8,10,21

Snell 37,56,61

Lindner 38,41

Drake et al 65