Lateral region of the neck. Scapular-trapezoid triangle of the neck. The borders of the scapular-trapezoid triangle. Scapular-clavicular triangle. Borders of the scapular-clavicular triangle. Back of the neck. The value of the scapular-trapezoid triangle
12.1. BORDERS, AREAS AND TRIANGLES OF THE NECK
The borders of the neck area are from above a line drawn from the chin along the lower edge of the lower jaw through the top of the mastoid process along the upper nuchal line to the external occipital tubercle, from below - a line from the jugular notch of the sternum along the upper edge of the clavicle to the clavicular-acromial joint and then to the spinous process of the seventh cervical vertebra.
The sagittal plane, drawn through the midline of the neck and the spinous processes of the cervical vertebrae, divides the neck region into right and left halves, and the frontal plane, drawn through the transverse processes of the vertebrae, into the anterior and posterior regions.
Each anterior region of the neck is divided by the sternocleidomastoid muscle into internal (medial) and external (lateral) triangles (Fig. 12.1).
The borders of the medial triangle are from above the lower edge of the lower jaw, behind - the anterior edge of the sternocleidomastoid muscle, in front - the median line of the neck. Within the medial triangle are the internal organs of the neck (larynx, trachea, pharynx, esophagus, thyroid and parathyroid glands) and there are a number of smaller triangles: submental triangle (trigonum submentale), submandibular triangle (trigonum submandibulare), sleepy triangle (trigonum caroticum), scapular-tracheal triangle (trigonum omotracheale).
The boundaries of the lateral triangle of the neck are from below the clavicle, medially - the posterior edge of the sternocleidomastoid muscle, behind - the edge of the trapezius muscle. The lower belly of the scapular-hyoid muscle divides it into the scapular-trapezius and scapular-clavicular triangles.
Rice. 12.1.Neck triangles:
1 - submandibular; 2 - sleepy; 3 - scapular-tracheal; 4 - scapular-trapezoid; 5 - scapular-clavicular
12.2. FASCIA AND CELLULAR SPACES OF THE NECK
12.2.1. Fascia of the neck
According to the classification proposed by V.N. Shevkunenko, 5 fasciae are distinguished on the neck (Fig. 12.2):
Superficial fascia of the neck (fascia superficialis colli);
Superficial sheet of own fascia of the neck (lamina superficialis fasciae colli propriae);
Deep sheet of own fascia of the neck (lamina profunda fascae colli propriae);
Intracervical fascia (fascia endocervicalis), consisting of two sheets - parietal (4 a - lamina parietalis) and visceral (lamina visceralis);
prevertebral fascia (fascia prevertebralis).
According to the International Anatomical Nomenclature, the second and third fascia of the neck, respectively, are called proper (fascia colli propria) and scapular-clavicular (fascia omoclavicularis).
The first fascia of the neck covers both its posterior and anterior surfaces, forming a sheath for the subcutaneous muscle of the neck (m. platysma). At the top, it goes to the face, and below - to the chest area.
The second fascia of the neck is attached to the front surface of the handle of the sternum and collarbones, and at the top - to the edge of the lower jaw. It gives spurs to the transverse processes of the vertebrae, and is attached to their spinous processes from behind. This fascia forms cases for the sternocleidomastoid (m. sternocleidomastoideus) and trapezius (m.trapezius) muscles, as well as for the submandibular salivary gland. The superficial sheet of fascia, which runs from the hyoid bone to the outer surface of the lower jaw, is dense and durable. The deep leaf reaches significant strength only at the borders of the submandibular bed: at the place of its attachment to the hyoid bone, to the internal oblique line of the lower jaw, during the formation of cases of the posterior belly of the digastric muscle and the stylohyoid muscle. In the area of the maxillo-hyoid and hyoid-lingual muscles, it is loosened and weakly expressed.
In the submental triangle, this fascia forms cases for the anterior bellies of the digastric muscles. Along the midline, formed by the suture of the maxillohyoid muscle, the superficial and deep sheets are fused together.
The third fascia of the neck starts from the hyoid bone, goes down, having the outer border of the scapular-hyoid muscle (m.omohyoideus), and below is attached to the back surface of the handle of the sternum and collarbones. It forms fascial sheaths for the sternohyoid (m. sternohyoideus), scapular-hyoid (m. omohyoideus), sternothyroid (m. sternothyrcoideus) and thyroid-hyoid (m. thyreohyoideus) muscles.
The second and third fasciae along the midline of the neck grow together in the gap between the hyoid bone and a point located 3-3.5 cm above the sternum handle. This formation is called the white line of the neck. Below this point, the second and third fasciae diverge, forming the suprasternal interaponeurotic space.
The fourth fascia at the top is attached to the outer base of the skull. It consists of parietal and visceral sheets. Visceral
the leaf forms cases for all organs of the neck (pharynx, esophagus, larynx, trachea, thyroid and parathyroid glands). It is equally well developed in both children and adults.
The parietal leaf of the fascia is connected by strong spurs to the prevertebral fascia. The pharyngeal-vertebral fascial spurs divide all the tissue around the pharynx and esophagus into the retro-pharyngeal and lateral pharyngeal (peri-pharyngeal) tissue. The latter, in turn, is divided into anterior and posterior sections, the boundary between which is the stylo-pharyngeal aponeurosis. The anterior section is the bottom of the submandibular triangle and descends to the hyoid muscle. The posterior section contains the common carotid artery, the internal jugular vein, the last 4 pairs of cranial nerves (IX, X, XI, XII), deep cervical lymph nodes.
Of practical importance is the spur of the fascia, which runs from the posterior pharyngeal wall to the prevertebral fascia, extending from the base of the skull to the III-IV cervical vertebrae and dividing the pharyngeal space into the right and left halves. From the borders of the posterior and lateral walls of the pharynx to the prevertebral fascia, spurs (Charpy's ligaments) stretch, separating the pharyngeal space from the posterior part of the peripharyngeal space.
The visceral sheet forms fibrous cases for organs and glands located in the region of the medial triangles of the neck - the pharynx, esophagus, larynx, trachea, thyroid and parathyroid glands.
The fifth fascia is located on the muscles of the spine, forms closed cases for the long muscles of the head and neck and passes to the muscles starting from the transverse processes of the cervical vertebrae.
The outer part of the prevertebral fascia consists of several spurs that form cases for the muscle that lifts the scapula, scalene muscles. These cases are closed and go to the scapula and I-II ribs. Between the spurs there are cellular fissures (prescalene and interscalene spaces), where the subclavian artery and vein pass, as well as the brachial plexus.
Fascia takes part in the formation of the fascial sheath of the brachial plexus and the subclavian neurovascular bundle. In the splitting of the prevertebral fascia, the cervical part of the sympathetic trunk is located. In the thickness of the prevertebral fascia are the vertebral, lower thyroid, deep and ascending cervical vessels, as well as the phrenic nerve.
Rice. 12.2.Topography of the neck on a horizontal cut:
1 - superficial fascia of the neck; 2 - superficial sheet of the own fascia of the neck; 3 - deep sheet of the own fascia of the neck; 4 - parietal sheet of the intracervical fascia; 5 - visceral sheet of the intracervical fascia; 6 - capsule of the thyroid gland; 7 - thyroid gland; 8 - trachea; 9 - esophagus; 10 - neurovascular bundle of the medial triangle of the neck; 11 - retrovisceral cellular space; 12 - prevertebral fascia; 13 - spurs of the second fascia of the neck; 14 - superficial muscle of the neck; 15 - sternohyoid and sternothyroid muscles; 16 - sternocleidomastoid muscle; 17 - scapular-hyoid muscle; 18 - internal jugular vein; 19 - common carotid artery; 20 - vagus nerve; 21 - border sympathetic trunk; 22 - scalene muscles; 23 - trapezius muscle
12.2.2. Cellular spaces
The most important and well-defined is the cellular space surrounding the inside of the neck. In the lateral sections, the fascial sheaths of the neurovascular bundles adjoin to it. The fiber surrounding the organs in front looks like a pronounced adipose tissue, and in the posterolateral sections - loose connective tissue.
In front of the larynx and trachea, there is a pretracheal cellular space, bounded from above by the fusion of the third fascia of the neck (a deep sheet of the own fascia of the neck) with the hyoid bone, from the sides by its fusion with the fascial sheaths of the neurovascular bundles of the medial triangle of the neck, behind by the trachea, down to 7-8 tracheal rings. On the anterior surface of the larynx, this cellular space is not expressed, but downward from the isthmus of the thyroid gland there is fatty tissue containing vessels [the lowest thyroid artery and veins (a. et vv. thyroideae imae)]. The pretracheal space in the lateral sections passes to the outer surface of the lobes of the thyroid gland. At the bottom, the pretracheal space along the lymphatic vessels connects with the tissue of the anterior mediastinum.
The pretracheal tissue posteriorly passes into the lateral paraesophageal space, which is a continuation of the parapharyngeal space of the head. The periesophageal space is bounded from the outside by the sheaths of the neurovascular bundles of the neck, and from behind by the lateral fascial spurs extending from the visceral sheet of the intracervical fascia, which forms the fibrous sheath of the esophagus, to the sheaths of the neurovascular bundles.
The retroesophageal (retrovisceral) cellular space is limited in front by the visceral sheet of the intracervical fascia on the posterior wall of the esophagus, in the lateral sections - by the pharyngeal-vertebral spurs. These spurs delimit the periesophageal and posterior esophageal spaces. The latter passes at the top into the pharyngeal tissue, divided into the right and left halves by a fascial sheet extending from the posterior pharyngeal wall to the spine in the sagittal plane. Down it does not descend below the VI-VII cervical vertebrae.
Between the second and third fascia, directly above the handle of the sternum, there is a suprasternal interfascial cellular space (spatium interaponeuroticum suprasternale). Its vertical size is 4-5 cm. To the sides of the midline is
the space communicates with Gruber's bags - cellular spaces located behind the lower sections of the sternocleidomastoid muscles. Above, they are delimited by adhesions of the second and third fascia of the neck (at the level of the intermediate tendons of the scapular-hyoid muscles), below - by the edge of the notch of the sternum and the upper surface of the sternoclavicular joints, from the outside they reach the lateral edge of the sternocleidomastoid muscles.
The fascial cases of the sternocleidomastoid muscles are formed by the superficial sheet of the neck's own fascia. At the bottom, they reach the attachment of the muscle to the clavicle, sternum and their articulation, and at the top - to the lower border of the formation of the tendon of the muscles, where they fuse with them. These cases are closed. To a greater extent, layers of adipose tissue are expressed on the back and inner surfaces of the muscles, to a lesser extent - on the front.
The anterior wall of the fascial sheaths of the neurovascular bundles, depending on the level, is formed either by the third (below the intersection of the sternocleidomastoid and scapular-hyoid muscles), or by the parietal sheet of the fourth (above this intersection) fascia of the neck. The posterior wall is formed by a spur of the prevertebral fascia. Each element of the neurovascular bundle has its own sheath, thus, the common neurovascular sheath consists of three in total - the sheath of the common carotid artery, the internal jugular vein and the vagus nerve. At the level of the intersection of the vessels and nerve with the muscles coming from the styloid process, they are tightly fixed to the back wall of the fascial sheaths of these muscles, and thus the lower part of the sheath of the neurovascular bundle is delimited from the posterior peripharyngeal space.
The prevertebral space is located behind the organs and behind the pharyngeal tissue. It is delimited by the common prevertebral fascia. Inside this space there are cellular gaps of fascial cases of individual muscles lying on the spine. These gaps are delimited from each other by the attachment of cases along with long muscles on the bodies of the vertebrae (below, these spaces reach the II-III thoracic vertebrae).
The fascial sheaths of the scalene muscles and trunks of the brachial plexus are located outward from the bodies of the cervical vertebrae. The plexus trunks are located between the anterior and middle scalene muscles. Interscalene space along the branches of the subclavian
artery connects with the prevertebral space (along the vertebral artery), with the pretracheal space (along the inferior thyroid artery), with the fascial case of the neck fat between the second and fifth fascia in the scapular-trapezoid triangle (along the transverse artery of the neck).
The fascial case of the neck fat pad is formed by the superficial sheet of the own fascia of the neck (in front) and the prevertebral (behind) fascia between the sternocleidomastoid and trapezius muscles in the scapular-trapezius triangle. Downward, the fatty tissue of this case descends into the scapular-clavicular triangle, located under the deep sheet of the own fascia of the neck.
Messages of the cellular spaces of the neck. The cellular spaces of the submandibular region have direct communication with both the submucosal tissue of the floor of the mouth and with the fatty tissue that fills the anterior peripharyngeal cellular space.
The post-pharyngeal space of the head passes directly into the tissue located behind the esophagus. At the same time, these two spaces are isolated from other cellular spaces of the head and neck.
The adipose tissue of the neurovascular bundle is well demarcated from neighboring cellular spaces. It is extremely rare that inflammatory processes spread to the posterior peripharyngeal space along the internal carotid artery and internal jugular vein. Also, a connection between this space and the anterior peripharyngeal space is rarely noted. This may be due to underdevelopment of the fascia between the stylohyoid and stylo-pharyngeal muscles. Downward, the fiber extends to the level of the venous angle (Pirogov) and the place of origin of its branches from the aortic arch.
The periesophageal space in most cases communicates with fiber located on the anterior surface of the cricoid cartilage and the lateral surface of the larynx.
The pretracheal space sometimes communicates with the periesophageal spaces, much less often with the anterior mediastinal tissue.
The suprasternal interfascial space with Gruber's bags are also isolated.
The fiber of the lateral triangle of the neck has messages along the trunks of the brachial plexus and branches of the subclavian artery.
12.3. FRONT REGION OF THE NECK
12.3.1. Submandibular triangle
The submandibular triangle (trigonum submandibulare) (Fig. 12.4) is limited by the anterior and posterior belly of the digastric muscle and the edge of the lower jaw, which forms the base of the triangle at the top.
Leathermobile and flexible.
The first fascia forms the sheath of the subcutaneous muscle of the neck (m. p1atysma), the fibers of which are directed from bottom to top and from outside to inside. The muscle starts from the thoracic fascia below the clavicle and ends on the face, partly connecting with the fibers of the facial muscles in the corner of the mouth, partly weaving into the parotid-masticatory fascia. The muscle is innervated by the cervical branch of the facial nerve (r. colli n. facialis).
Between the back wall of the vagina of the subcutaneous muscle of the neck and the second fascia of the neck, immediately under the edge of the lower jaw lies one or more superficial submandibular lymph nodes. In the same layer, the upper branches of the transverse nerve of the neck (n. transversus colli) pass from the cervical plexus (Fig. 12.3).
Under the second fascia in the region of the submandibular triangle are the submandibular gland, muscles, lymph nodes, vessels and nerves.
The second fascia forms the capsule of the submandibular gland. The second fascia has two leaves. Superficial, covering the outer surface of the gland, is attached to the lower edge of the lower jaw. Between the angle of the lower jaw and the anterior edge of the sternocleidomastoid muscle, the fascia thickens, giving inward a dense septum separating the bed of the submandibular gland from the bed of the parotid. Heading towards the midline, the fascia covers the anterior belly of the digastric muscle and the maxillohyoid muscle. The submandibular gland partially adjoins directly to the bone, the inner surface of the gland adjoins the maxillo-hyoid and hyoid-lingual muscles, separated from them by a deep sheet of the second fascia, which is significantly inferior in density to the surface sheet. At the bottom, the capsule of the gland is connected to the hyoid bone.
The capsule surrounds the gland freely, without growing together with it and without giving processes into the depths of the gland. Between the submandibular gland and its capsule there is a layer of loose fiber. The bed of the gland is closed from all
sides, especially at the level of the hyoid bone, where the superficial and deep leaves of its capsule grow together. Only in the anterior direction, the fiber contained in the gland bed communicates along the gland duct in the gap between the maxillohyoid and hyoid-lingual muscles with the fiber of the floor of the mouth.
The submandibular gland fills the gap between the anterior and posterior belly of the digastric muscle; it either does not go beyond the triangle, which is characteristic of old age, or is large and then goes beyond its limits, which is observed at a young age. In older people, the submandibular gland is sometimes well contoured due to partial atrophy of the subcutaneous tissue and the subcutaneous muscle of the neck.
Rice. 12.3.Superficial nerves of the neck:
1 - cervical branch of the facial nerve; 2 - large occipital nerve; 3 - small occipital nerve; 4 - posterior ear nerve; 5 - transverse nerve of the neck; 6 - anterior supraclavicular nerve; 7 - middle supraclavicular nerve; 8 - posterior supraclavicular nerve
The submandibular gland has two processes extending beyond the gland bed. The posterior process goes under the edge of the lower jaw and reaches the place of attachment to it of the internal pterygoid muscle. The anterior process accompanies the excretory duct of the gland and, together with it, passes into the gap between the maxillofacial and hyoid-lingual muscles, often reaching the sublingual salivary gland. The latter lies under the mucous membrane of the bottom of the mouth on the upper surface of the maxillohyoid muscle.
Around the gland lie the submandibular lymph nodes, adjacent mainly to the upper and posterior edges of the gland, where the anterior facial vein passes. Often, the presence of lymph nodes is also noted in the thickness of the gland, as well as between the sheets of the fascial septum that separates the posterior end of the submandibular gland from the lower end of the parotid gland. The presence of lymph nodes in the thickness of the submandibular gland makes it necessary to remove not only the submandibular lymph nodes, but also the submandibular salivary gland (if necessary, from both sides) in case of metastases of cancerous tumors (for example, the lower lip).
The excretory duct of the gland (ductus submandibularis) starts from the inner surface of the gland and stretches anteriorly and upward, penetrating into the gap between m. hyoglossus and m. mylohyoideus and further passing under the mucous membrane of the bottom of the mouth. The specified intermuscular gap, which passes the salivary duct, surrounded by loose fiber, can serve as a path along which pus, with phlegmon of the bottom of the mouth, descends into the region of the submandibular triangle. Below the duct, the hypoglossal nerve (n. hypoglossus) penetrates into the same gap, accompanied by the lingual vein (v. lingualis), and above the duct it goes, accompanied by the lingual nerve (n. lingualis).
Deeper than the submandibular gland and the deep plate of the second fascia are muscles, vessels and nerves.
Within the submandibular triangle, the superficial layer of muscles consists of the digastric (m. digastricum), stylohyoid (m. stylohyoideus), maxillary-hyoid (m.mylohyoideus) and hyoid-lingual (m. hyoglossus) muscles. The first two limit (with the edge of the lower jaw) the submandibular triangle, the other two form its bottom. The digastric muscle with the posterior belly starts from the mastoid notch of the temporal bone, the anterior - from the fossa of the lower jaw of the same name, and the tendon connecting both abdomens is attached to the body of the hyoid bone. To the back belly
The digastric muscle adjoins the stylohyoid muscle, which starts from the styloid process and attaches to the body of the hyoid bone, while covering the tendon of the digastric muscle with its legs. The maxillohyoid muscle lies deeper than the anterior belly of the digastric muscle; it starts from the line of the same name of the lower jaw and is attached to the body of the hyoid bone. The right and left muscles converge in the midline, forming a seam (raphe). Both muscles make up an almost quadrangular plate that forms the so-called diaphragm of the mouth.
The hyoid-lingual muscle is, as it were, a continuation of the jaw-hyoid muscle. However, the maxillary-hyoid muscle is connected with the lower jaw with its other end, while the hyoid-lingual muscle goes to the lateral surface of the tongue. The lingual vein, the hypoglossal nerve, the duct of the submandibular salivary gland and the lingual nerve pass along the outer surface of the hyoid-lingual muscle.
The facial artery always passes in the fascial bed under the edge of the mandible. In the submandibular triangle, the facial artery makes a bend, passing along the upper and posterior surfaces of the posterior pole of the submandibular gland near the pharyngeal wall. In the thickness of the superficial plate of the second fascia of the neck passes the facial vein. At the posterior border of the submandibular triangle, it merges with the posterior mandibular vein (v. retromandibularis) into the common facial vein (v. facialis communis).
In the gap between the maxillohyoid and hyoid-lingual muscle, the lingual nerve passes, giving off branches to the submandibular salivary gland.
A small area of the area of \u200b\u200bthe triangle, where the lingual artery can be exposed, is called Pirogov's triangle. Its borders: the upper one is the hypoglossal nerve, the lower one is the intermediate tendon of the digastric muscle, the anterior one is the free edge of the maxillohyoid muscle. The bottom of the triangle is the hyoid-lingual muscle, the fibers of which must be separated to expose the artery. Pirogov's triangle is revealed only on condition that the head is thrown back and strongly turned in the opposite direction, and the gland is removed from its bed and pulled upward.
Submandibular lymph nodes (nodi lymphatici submandibulares) are located on top, in the thickness or under the surface plate of the second fascia of the neck. They drain lymph from the medial
Rice. 12.4.Topography of the submandibular triangle of the neck: 1 - own fascia; 2 - angle of the lower jaw; 3 - posterior belly of the digastric muscle; 4 - anterior belly of the digastric muscle; 5 - hyoid-lingual muscle; 6 - maxillofacial muscle; 7 - Pirogov's triangle; 8 - submandibular gland; 9 - submandibular lymph nodes; 10 - external carotid artery; 11 - lingual artery; 12 - lingual vein; 13 - hypoglossal nerve; 14 - common facial vein; 15 - internal jugular vein; 16 - facial artery; 17 - facial vein; 18 - mandibular vein
parts of the eyelids, external nose, buccal mucosa, gums, lips, floor of the mouth and middle part of the tongue. Thus, during inflammatory processes in the area of the inner part of the lower eyelid, the submandibular lymph nodes increase.
12.3.2. sleepy triangle
The sleepy triangle (trigonum caroticum) (Fig. 12.5), is bounded laterally by the anterior edge of the sternocleidomastoid muscle, from above by the posterior belly of the digastric muscle and the stylohyoid muscle, from the inside by the upper belly of the scapular-hyoid muscle.
Leatherthin, mobile, easily taken in a fold.
Innervation is carried out by the transverse nerve of the neck (n. transverses colli) from the cervical plexus.
The superficial fascia contains the fibers of the subcutaneous muscle of the neck.
Between the first and second fascia is the transverse nerve of the neck (n. transversus colli) from the cervical plexus. One of its branches goes to the body of the hyoid bone.
The superficial sheet of the own fascia of the neck under the sternocleidomastoid muscle fuses with the sheath of the neurovascular bundle formed by the parietal sheet of the fourth fascia of the neck.
In the sheath of the neurovascular bundle, the internal jugular vein is located laterally, medially - the common carotid artery (a. carotis communis), and behind them - the vagus nerve (n.vagus). Each element of the neurovascular bundle has its own fibrous sheath.
The common facial vein (v. facialis communis) flows into the vein from above and medially at an acute angle. In the corner at the place of their confluence, a large lymph node may be located. Along a vein in her vagina is a chain of deep lymph nodes in the neck.
On the surface of the common carotid artery, the upper root of the cervical loop descends from top to bottom and medially.
At the level of the upper edge of the thyroid cartilage, the common carotid artery divides into external and internal. The external carotid artery (a.carotis externa) is usually located more superficial and medial, and the internal carotid is lateral and deeper. This is one of the signs of the differences between the vessels from each other. Another distinguishing feature is the presence of branches in the external carotid artery and their absence in the internal carotid. In the bifurcation area, there is a slight expansion that continues to the internal carotid artery - the carotid sinus (sinus caroticus).
On the posterior (sometimes on the medial) surface of the internal carotid artery is the carotid tangle (glomus caroticum). In the fatty tissue surrounding the carotid sinus and carotid tangle, lies the nerve plexus, formed by the branches of the glossopharyngeal, vagus nerves and the border sympathetic trunk. This is a reflexogenic zone containing baro- and chemoreceptors that regulate blood circulation and respiration through the nerve of Hering, together with the nerve of Ludwig-Zion.
The external carotid artery is located in the angle formed by the trunk of the common facial vein from the inside, by the internal jugular vein laterally, by the hypoglossal nerve from above (Farabeuf's triangle).
At the place where the external carotid artery is formed, there is the superior thyroid artery (a.thyroidea superior), which goes medially and downwards, going under the edge of the upper abdomen of the scapular-hyoid muscle. At the level of the upper edge of the thyroid cartilage, the superior laryngeal artery departs from this artery in the transverse direction.
Rice. 12.5.Topography of the carotid triangle of the neck:
1 - posterior belly of the digastric muscle; 2 - upper abdomen of the scapular-hyoid muscle; 3 - sternocleidomastoid muscle; 4 - thyroid gland; 5 - internal jugular vein; 6 - facial vein; 7 - lingual vein; 8 - superior thyroid vein; 9 - common carotid artery; 10 - external carotid artery; 11 - superior thyroid artery; 12 - lingual artery; 13 - facial artery; 14 - vagus nerve; 15 - hypoglossal nerve; 16 - superior laryngeal nerve
Slightly above the origin of the superior thyroid artery at the level of the large horn of the hyoid bone, directly below the hypoglossal nerve on the anterior surface of the external carotid artery is the mouth of the lingual artery (a. lingualis), which is hidden under the outer edge of the hyoid-lingual muscle.
At the same level, but from the inner surface of the external carotid artery, the ascending pharyngeal artery departs (a.pharyngea ascendens).
Above the lingual artery departs the facial artery (a.facialis). It goes up and medially under the posterior belly of the digastric muscle, pierces a deep sheet of the second fascia of the neck and, making a bend in the medial side, enters the bed of the submandibular salivary gland (see Fig. 12.4).
At the same level, the sternocleidomastoid artery (a. sternocleidomastoidea) departs from the lateral surface of the external carotid artery.
On the posterior surface of the external carotid artery, at the level of the origin of the facial and sternocleidomastoid arteries, there is the mouth of the occipital artery (a.occipitalis). It goes back and up along the lower edge of the posterior belly of the digastric muscle.
Under the posterior belly of the digastric muscle anterior to the internal carotid artery is the hypoglossal nerve, which forms an arc with a bulge downwards. The nerve goes forward under the lower edge of the digastric muscle.
The superior laryngeal nerve (n. laryngeus superior) is located at the level of the large horn of the hyoid bone behind both carotid arteries on the prevertebral fascia. It is divided into two branches: internal and external. The internal branch goes down and forward, accompanied by the superior laryngeal artery (a.laryngeа superior), located below the nerve. Further, it perforates the thyroid-hyoid membrane and penetrates the wall of the larynx. The external branch of the superior laryngeal nerve runs vertically downward to the cricothyroid muscle.
The cervical region of the borderline sympathetic trunk is located under the fifth fascia of the neck immediately medially from the palpable anterior tubercles of the transverse processes of the cervical vertebrae. It lies directly on the long muscles of the head and neck. At the level of Th n -Th ni is the upper cervical sympathetic node, reaching 2-4 cm in length and 5-6 mm in width.
12.3.3. Scapulotracheal triangle
The scapular-tracheal triangle (trigonum omotracheale) is bounded above and behind by the upper abdomen of the scapular-hyoid muscle, below and behind by the anterior edge of the sternocleidomastoid muscle, and in front by the median line of the neck. The skin is thin, mobile, easily stretched. The first fascia forms the sheath of the subcutaneous muscle.
The second fascia fuses along the upper border of the region with the hyoid bone, and below it is attached to the anterior surface of the sternum and clavicle. In the midline, the second fascia fuses with the third, however, for about 3 cm upward from the jugular notch, both fascial sheets exist as independent plates, delimit the cellular space (spatium interaponeuroticum suprasternale).
The third fascia has a limited extent: at the top and bottom it is connected with the bone borders of the region, and from the sides it ends along the edges of the scapular-hyoid muscles connected to it. Merging in the upper half of the region with the second fascia along the midline, the third fascia forms the so-called white line of the neck (linea alba colli) 2-3 mm wide.
The third fascia forms the sheath of 4 paired muscles located below the hyoid bone: mm. sternohyoideus, sternothyroideus, thyrohyoideus, omohyoideus.
The sternohyoid and sternothyroid muscles originate most of the fibers from the sternum. The sternohyoid muscle is longer and narrower, lies closer to the surface, the sternothyroid muscle is wider and shorter, lies deeper and is partially covered by the previous muscle. The sternohyoid muscle is attached to the body of the hyoid bone, converging near the midline with the same muscle of the opposite side; the sternothyroid muscle is attached to the thyroid cartilage, and, going up from the sternum, it diverges from the same muscle of the opposite side.
The thyroid-hyoid muscle is, to a certain extent, a continuation of the sternothyroid muscle and stretches from the thyroid cartilage to the hyoid bone. The scapular-hyoid muscle has two abdomens - lower and upper, the first being connected with the upper edge of the scapula, the second with the body of the hyoid bone. Between both abdomens of the muscle there is an intermediate tendon. The third fascia ends along the outer edge of the muscle, firmly fuses with its intermediate tendon and the wall of the internal jugular vein.
Under the described layer of muscles with their vaginas there are sheets of the fourth fascia of the neck (fascia endocervicalis), which consists of a parietal sheet covering the muscles and a visceral one. Under the visceral sheet of the fourth fascia are the larynx, trachea, thyroid gland (with parathyroid glands), pharynx, esophagus.
12.4. TOPOGRAPHY OF THE LARYNX AND CERVICAL TRACHEA
Larynx(larynx) form 9 cartilages (3 paired and 3 unpaired). The basis of the larynx is the cricoid cartilage, located at the level of the VI cervical vertebra. Above the anterior part of the cricoid cartilage is the thyroid cartilage. The thyroid cartilage is connected with the hyoid bone by the membrane (membrana hyothyroidea), from the cricoid cartilage to the thyroid cartilage go mm. cricothyroidei and ligg. cricoarytenoidei.
Three sections are distinguished in the cavity of the larynx: the upper (vestibulum laryngis), the middle one, corresponding to the position of the false and true vocal cords, and the lower one, called the subglottic space in laryngology (Fig. 12.6, 12.7).
Skeletotopia.The larynx is located in the range from the upper edge of the V cervical vertebra to the lower edge of the VI cervical vertebra. The upper part of the thyroid cartilage can reach the level of the IV cervical vertebra. In children, the larynx lies much higher, reaching the level of the III vertebra with its upper edge, in the elderly it lies low, located with its upper edge at the level of the VI vertebra. The position of the larynx changes dramatically in the same person depending on the position of the head. So, with the tongue sticking out, the larynx rises, the epiglottis takes a position close to vertical, opening the entrance to the larynx.
Blood supply.The larynx is supplied by branches of the superior and inferior thyroid arteries.
innervationThe larynx is carried out by the pharyngeal plexus, which is formed by the branches of the sympathetic, vagus and glossopharyngeal nerves. The superior and inferior laryngeal nerves (n. laringeus superior et inferior) are branches of the vagus nerve. At the same time, the superior laryngeal nerve, being predominantly sensitive,
innervates the mucous membrane of the upper and middle sections of the larynx, as well as the cricothyroid muscle. The inferior laryngeal nerve, being predominantly motor, innervates the muscles of the larynx and the mucous membrane of the lower larynx.
Rice. 12.6.Organs and blood vessels of the neck:
1 - hyoid bone; 2 - trachea; 3 - lingual vein; 4 - upper thyroid artery and vein; 5 - thyroid gland; 6 - left common carotid artery; 7 - left internal jugular vein; 8 - left anterior jugular vein, 9 - left external jugular vein; 10 - left subclavian artery; 11 - left subclavian vein; 12 - left brachiocephalic vein; 13 - left vagus nerve; 14 - right brachiocephalic vein; 15 - right subclavian artery; 16 - right anterior jugular vein; 17 - brachiocephalic trunk; 18 - the smallest thyroid vein; 19 - right external jugular vein; 20 - right internal jugular vein; 21 - sternocleidomastoid muscle
Rice. 12.7.Cartilages, ligaments and joints of the larynx (from: Mikhailov S.S. et al., 1999) a - front view: 1 - hyoid bone; 2 - granular cartilage; 3 - upper horn of the thyroid cartilage; 4 - left plate of the thyroid cartilage;
5 - lower horn of the thyroid cartilage; 6 - arc of the cricoid cartilage; 7 - cartilage of the trachea; 8 - annular ligaments of the trachea; 9 - cricoid joint; 10 - cricoid ligament; 11 - upper thyroid notch; 12 - thyroid membrane; 13 - median thyroid ligament; 14 - lateral thyroid-hyoid ligament.
6 - rear view: 1 - epiglottis; 2 - large horn of the hyoid bone; 3 - granular cartilage; 4 - upper horn of the thyroid cartilage; 5 - right plate of the thyroid cartilage; 6 - arytenoid cartilage; 7, 14 - right and left cricoarytenoid cartilages; 8, 12 - right and left cricoid joints; 9 - cartilage of the trachea; 10 - membranous wall of the trachea; 11 - plate of the cricoid cartilage; 13 - lower horn of the thyroid cartilage; 15 - muscular process of the arytenoid cartilage; 16 - vocal process of the arytenoid cartilage; 17 - thyroid-epiglottic ligament; 18 - corniculate cartilage; 19 - lateral thyroid-hyoid ligament; 20 - thyroid membrane
Lymph drainage.With regard to lymph drainage, it is customary to divide the larynx into two sections: the upper one - above the vocal cords and the lower one - below the vocal cords. Regional lymph nodes of the upper larynx are mainly deep cervical lymph nodes located along the internal jugular vein. Lymphatic vessels from the lower part of the larynx end in nodes located near the trachea. These nodes are associated with deep cervical lymph nodes.
Trachea - is a tube consisting of 15-20 cartilaginous half-rings, making up approximately 2/3-4/5 of the circumference of the trachea and closed behind by a connective tissue membrane, and interconnected by annular ligaments.
The membranous membrane contains, in addition to running in the longitudinal direction of elastic and collagen fibers, also running in the longitudinal and oblique directions of smooth muscle fibers.
From the inside, the trachea is covered with a mucous membrane, in which the most superficial layer is a multilayered ciliated cylindrical epithelium. A large number of goblet cells located in this layer produce, together with the tracheal glands, a thin layer of mucus that protects the mucous membrane. The middle layer of the mucous membrane is called the basement membrane and consists of a network of argyrophilic fibers. The outer layer of the mucous membrane is formed by elastic fibers located in the longitudinal direction, especially developed in the region of the membranous part of the trachea. Due to this layer, folding of the mucous membrane is formed. Between the folds, the excretory tubules of the tracheal glands open. Due to the pronounced submucosal layer, the mucous membrane of the trachea is mobile, especially in the area of the membranous part of its wall.
Outside, the trachea is covered with a fibrous sheet, which consists of three layers. The outer leaflet is intertwined with the outer perichondrium, and the inner leaflet is intertwined with the inner perichondrium of the cartilaginous semirings. The middle layer is fixed along the edges of the cartilaginous semirings. Between these layers of fibrous fibers are adipose tissue, blood vessels and glands.
Distinguish between the cervical and thoracic trachea.
The total length of the trachea varies in adults from 8 to 15 cm, in children it varies depending on age. In men, it is 10-12 cm, in women - 9-10 cm. The length and width of the trachea in adults depend on the type of physique. So, with a brachymorphic body type, it is short and wide, with a dolichomorphic body type, it is narrow and long. In children
For the first 6 months of life, the funnel-shaped form of the trachea predominates; with age, the trachea acquires a cylindrical or conical shape.
Skeletotopia.The onset of the cervical region depends on age in children and body type in adults, in which it ranges from the lower edge of the VI cervical to the lower edge of the II thoracic vertebrae. The boundary between the cervical and thoracic regions is the upper thoracic inlet. According to various researchers, the thoracic trachea can be 2/5-3/5 in children of the first years of life, in adults - from 44.5 - 62% of its total length.
Syntopy.In children, a relatively large thymus gland is adjacent to the anterior surface of the trachea, which in small children can rise to the lower edge of the thyroid gland. The thyroid gland in newborns is located relatively high. Its lateral lobes with their upper edges reach the level of the upper edge of the thyroid cartilage, and the lower ones - 8-10 tracheal rings and almost come into contact with the thymus gland. The isthmus of the thyroid gland in newborns is adjacent to the trachea for a relatively large extent and occupies a higher position. Its upper edge is located at the level of the cricoid cartilage of the larynx, and the lower one reaches the 5-8th tracheal rings, while in adults it is located between the 1st and 4th rings. The thin pyramidal process is relatively common and is located near the midline.
In adults, the upper part of the cervical trachea is surrounded in front and on the sides by the thyroid gland, behind it is the esophagus, separated from the trachea by a layer of loose fiber.
The upper cartilages of the trachea are covered by the isthmus of the thyroid gland, in the lower part of the cervical part of the trachea are the lower thyroid veins and the unpaired thyroid venous plexus. Above the jugular notch of the manubrium of the sternum in people of the brachymorphic body type, the upper edge of the left brachiocephalic vein is quite often located.
The recurrent laryngeal nerves lie in the esophageal-tracheal grooves formed by the esophagus and trachea. In the lower part of the neck, the common carotid arteries are adjacent to the lateral surfaces of the trachea.
The esophagus is adjacent to the thoracic part of the trachea, in front at the level of the IV thoracic vertebrae immediately above the bifurcation of the trachea and to the left of it is the aortic arch. On the right and in front, the brachiocephalic trunk covers the right semicircle of the trachea. Here, not far from the trachea, are the trunk of the right vagus nerve and the upper hollow
vein. Above the aortic arch lies the thymus gland or its replacement fatty tissue. To the left of the trachea is the left recurrent laryngeal nerve, and above it is the left common carotid artery. To the right and left of the trachea and below the bifurcation are numerous groups of lymph nodes.
Along the trachea in front are the suprasternal interaponeurotic, pretracheal and peritracheal cellular spaces containing the unpaired venous plexus of the thyroid gland, the inferior thyroid artery (in 10-12% of cases), lymph nodes, vagus nerves, cardiac branches of the border sympathetic trunk.
blood supplythe cervical part of the trachea is carried out by branches of the lower thyroid arteries or thyroid trunks. The blood flow to the thoracic trachea occurs due to the bronchial arteries, as well as from the arch and descending part of the aorta. Bronchial arteries in the amount of 4 (sometimes 2-6) most often depart from the anterior and right semicircle of the descending part of the thoracic aorta on the left, less often - from 1-2 intercostal arteries or the descending part of the aorta on the right. They can start from the subclavian, inferior thyroid arteries and from the costocervical trunk. In addition to these constant sources of blood supply, there are additional branches extending from the aortic arch, brachiocephalic trunk, subclavian, vertebral, internal thoracic and common carotid arteries.
Before entering the lungs, the bronchial arteries give parietal branches in the mediastinum (to the muscles, spine, ligaments and pleura), visceral branches (to the esophagus, pericardium), adventitia of the aorta, pulmonary vessels, unpaired and semi-unpaired veins, to the trunks and branches of the sympathetic and vagus nerves and also to the lymph nodes.
In the mediastinum, the bronchial arteries anastomose with the esophageal, pericardial arteries, branches of the internal thoracic and inferior thyroid arteries.
venous outflow.The venous vessels of the trachea are formed from intra- and extra-organ venous networks of the mucous, deep submucosal and superficial plexuses. Venous outflow is carried out through the lower thyroid veins, which flow into the unpaired thyroid venous plexus, the veins of the cervical esophagus, and from the thoracic region into the unpaired and semi-unpaired veins, sometimes into the brachiocephalic veins, and also anastomose with the veins of the thymus gland, mediastinal fiber, and thoracic esophagus .
Innervation.The cervical part of the trachea is innervated by tracheal branches of the recurrent laryngeal nerves with the inclusion of branches from the cervical cardiac nerves, cervical sympathetic nodes and internodal branches, and in some cases from the thoracic sympathetic trunk. In addition, sympathetic branches to the trachea also come from the common carotid and subclavian plexuses. Branches from the recurrent laryngeal nerve, from the main trunk of the vagus nerve, and to the left, from the left recurrent laryngeal nerve, approach the thoracic trachea on the right. These branches of the vagus and sympathetic nerves form closely interconnected superficial and deep plexuses.
Lymph drainage.Lymph capillaries form two networks in the mucosa of the trachea - superficial and deep. The submucosa contains a plexus of efferent lymphatic vessels. In the muscular layer of the membranous part, the lymphatic vessels are located only between individual muscle bundles. In the adventitia, the efferent lymphatic vessels are located in two layers. Lymph from the cervical part of the trachea flows into the lower deep cervical, pretracheal, paratracheal, pharyngeal lymph nodes. Part of the lymphatic vessels carry lymph to the anterior and posterior mediastinal nodes.
The lymphatic vessels of the trachea are connected with the vessels of the thyroid gland, pharynx, trachea and esophagus.
12.5. THYROID TOPOGRAPHY
AND PARATHYROID GLANDS
The thyroid gland (glandula thyroidea) consists of two lateral lobes and an isthmus. In each lobe of the gland, the upper and lower poles are distinguished. The upper poles of the lateral lobes of the thyroid gland reach the middle of the height of the plates of the thyroid cartilage. The lower poles of the lateral lobes of the thyroid gland descend below the isthmus and reach the level of the 5-6th ring, 2-3 cm short of the notch of the sternum. Approximately in 1/3 of cases, there is a presence of a pyramidal lobe extending upward from the isthmus in the form of an additional lobe of the gland (lobus pyramidalis). The latter may be associated not with the isthmus, but with the lateral lobe of the gland, and often reaches the hyoid bone. The size and position of the isthmus is highly variable.
The isthmus of the thyroid gland lies in front of the trachea (at the level of the 1st to 3rd or 2nd to 5th cartilage of the trachea). Sometimes (in 10-15% of cases) the isthmus of the thyroid gland is absent.
The thyroid gland has its own capsule in the form of a thin fibrous plate and a fascial sheath formed by the visceral sheet of the fourth fascia. From the capsule of the thyroid gland into the depths of the parenchyma of the organ, connective tissue septa extend. Allocate partitions of the first and second orders. In the thickness of the connective tissue partitions, intraorganic blood vessels and nerves pass. Between the capsule of the gland and its vagina there is loose fiber, in which arteries, veins, nerves and parathyroid glands lie.
In some places denser fibers depart from the fourth fascia, which have the character of ligaments passing from the gland to neighboring organs. The median ligament is stretched transversely between the isthmus, on the one hand, and the cricoid cartilage and the 1st cartilage of the trachea, on the other. The lateral ligaments run from the gland to the cricoid and thyroid cartilages.
Syntopy.The isthmus of the thyroid gland lies in front of the trachea at the level from the 1st to the 3rd or from the 2nd to the 4th of its cartilage, and often covers part of the cricoid cartilage. The lateral lobes through the fascial capsule come into contact with the fascial sheaths of the common carotid arteries with their posterolateral surfaces. The posterior medial surfaces of the lateral lobes are adjacent to the larynx, trachea, tracheoesophageal groove, and also to the esophagus, and therefore, with an increase in the lateral lobes of the thyroid gland, its compression is possible. In the gap between the trachea and the esophagus on the right and along the anterior wall of the esophagus on the left, recurrent laryngeal nerves rise to the cricoid ligament, lying outside the fascial capsule of the thyroid gland. Front cover the thyroid gland mm. sternohyoidei, sternothyroidei and omohyoidei.
blood supplyThe thyroid gland is carried out by branches of four arteries: two aa. thyroideae superiores and two aa. thyroideae inferiores. In rare cases (6-8%), in addition to these arteries, there is a. thyroidea ima, extending from the brachiocephalic trunk or from the aortic arch and heading towards the isthmus.
A. thyroidea superior supplies blood to the upper poles of the lateral lobes and the upper edge of the isthmus of the thyroid gland. A. thyroidea inferior departs from truncus thyrocervicalis in the scalo-vertebral gap
and rises under the fifth fascia of the neck along the anterior scalene muscle up to the level of the VI cervical vertebra, forming a loop or arc here. Then it descends downward and inwards, perforating the fourth fascia, to the lower third of the posterior surface of the lateral lobe of the gland. The ascending part of the inferior thyroid artery runs medially from the phrenic nerve. At the posterior surface of the lateral lobe of the thyroid gland, the branches of the inferior thyroid artery cross the recurrent laryngeal nerve, being anterior or posterior to it, and sometimes envelop the nerve in the form of a vascular loop.
The arteries of the thyroid gland (Fig. 12.8) form two systems of collaterals: intraorganic (due to the thyroid arteries) and extraorganic (due to anastomoses with the vessels of the pharynx, esophagus, larynx, trachea and adjacent muscles).
venous outflow.Veins form plexuses around the lateral lobes and isthmus, especially on the anterolateral surface of the gland. The plexus lying on and below the isthmus is called the plexus venosus thyreoideus impar. The inferior thyroid veins arise from it, flowing more often into the corresponding innominate veins, and the lowest thyroid veins vv. thyroideae imae (one or two), flowing into the left innominate. The superior thyroid veins drain into the internal jugular vein (directly or through the common facial vein). The inferior thyroid veins are formed from the venous plexus on the anterior surface of the gland, as well as from the unpaired venous plexus (plexus thyroideus impar), located at the lower edge of the isthmus of the thyroid gland and in front of the trachea, and flow into the right and left brachiocephalic veins, respectively. The thyroid veins form numerous intraorgan anastomoses.
Innervation.The thyroid nerves arise from the border trunk of the sympathetic nerve and from the superior and inferior laryngeal nerves. The inferior laryngeal nerve comes into close contact with the inferior thyroid artery, crossing it on its way. Among other vessels, the inferior thyroid artery is ligated when the goiter is removed; if the ligation is performed near the gland, then damage to the lower laryngeal nerve or its involvement in the ligature is possible, which can lead to paresis of the vocal muscles and phonation disorder. The nerve passes either in front of the artery or behind, and on the right it often lies in front of the artery, and on the left - behind.
Lymph drainagefrom the thyroid gland occurs mainly in the nodes located in front and on the sides of the trachea (nodi lymphatici
praetracheales et paratracheales), partially - in the deep cervical lymph nodes (Fig. 12.9).
Closely related to the thyroid gland are the parathyroid glands (glandulae parathyroideae). Usually in the amount of 4, they are most often located outside the thyroid capsule itself.
Rice. 12.8.Sources of blood supply to the thyroid and parathyroid glands: 1 - brachiocephalic trunk; 2 - right subclavian artery; 3 - right common carotid artery; 4 - right internal carotid artery; 5 - right external carotid artery; 6 - left upper thyroid artery; 7 - left lower thyroid artery; 8 - the lowest thyroid artery; 9 - left thyroid trunk
Rice. 12.9. Lymph nodes of the neck:
1 - pretracheal nodes; 2 - anterior thyroid nodes; 3 - chin nodes, 4 - mandibular nodes; 5 - buccal nodes; 6 - occipital nodes; 7 - parotid nodes; 8 - posterior nodes, 9 - upper jugular nodes; 10 - upper pull-out nodes; 11 - lower jugular and supraclavicular nodes
glands (between the capsule and the fascial sheath), two on each side, on the back surface of its lateral lobes. Significant differences are noted both in the number and size, and in the position of the parathyroid glands. Sometimes they are located outside the fascial sheath of the thyroid gland. As a result, finding the parathyroid glands during surgical interventions presents significant difficulties, especially due to the fact that next to the parathyroid
prominent glands are very similar in appearance to formations (lymph nodes, fatty lumps, additional thyroid glands).
To establish the true nature of the parathyroid gland removed during surgery, a microscopic examination is performed. To prevent complications associated with the erroneous removal of the parathyroid glands, it is advisable to use microsurgical techniques and tools.
12.6. sternocleidomastoid region
The sternocleidomastoid region (regio sternocleidomastoidea) corresponds to the position of the muscle of the same name, which is the main external landmark. The sternocleidomastoid muscle covers the medial neurovascular bundle of the neck (common carotid artery, internal jugular vein, and vagus nerve). In the carotid triangle, the neurovascular bundle is projected along the anterior edge of this muscle, and in the lower one it is covered by its sternal portion.
At the middle of the posterior edge of the sternocleidomastoid muscle, the exit point of the sensitive branches of the cervical plexus is projected. The largest of these branches is the large ear nerve (n. auricularis magnus). Pirogov's venous angle, as well as the vagus and phrenic nerves, are projected between the legs of this muscle.
Leatherthin, easily folded together with subcutaneous tissue and superficial fascia. Near the mastoid process, the skin is dense, inactive.
Subcutaneous adipose tissue loose. At the upper border of the area, it thickens and becomes cellular due to connective tissue bridges connecting the skin with the periosteum of the mastoid process.
Between the first and second fascia of the neck are the external jugular vein, superficial cervical lymph nodes and cutaneous branches of the cervical plexus of the spinal nerves.
The external jugular vein (v. jugularis extema) is formed by the confluence of the occipital, ear and partially mandibular veins at the angle of the lower jaw and goes down, obliquely crossing m. sternocleidomastoideus, to the top of the angle formed by the posterior edge of the sternocleidomastoid muscle and the upper edge of the clavicle.
Rice. 12.10.Arteries of the head and neck (from: Sinelnikov R.D., 1979): 1 - parietal branch; 2 - frontal branch; 3 - zygomatic-orbital artery; 4 - supraorbital artery; 5 - supratrochlear artery; 6 - ophthalmic artery; 7 - artery of the back of the nose; 8 - sphenoid palatine artery; 9 - angular artery; 10 - infraorbital artery; 11 - posterior superior alveolar artery;
12 - buccal artery; 13 - anterior superior alveolar artery; 14 - superior labial artery; 15 - pterygoid branches; 16 - artery of the back of the tongue; 17 - deep artery of the tongue; 18 - lower labial artery; 19 - chin artery; 20 - lower alveolar artery; 21 - hyoid artery; 22 - submental artery; 23 - ascending palatine artery; 24 - facial artery; 25 - external carotid artery; 26 - lingual artery; 27 - hyoid bone; 28 - suprahyoid branch; 29 - sublingual branch; 30 - superior laryngeal artery; 31 - superior thyroid artery; 32 - sternocleidomastoid branch; 33 - cricoid-thyroid branch; 34 - common carotid artery; 35 - lower thyroid artery; 36 - thyroid trunk; 37 - subclavian artery; 38 - brachiocephalic trunk; 39 - internal thoracic artery; 40 - aortic arch; 41 - costal-cervical trunk; 42 - suprascapular artery; 43 - deep artery of the neck; 44 - superficial branch; 45 - vertebral artery; 46 - ascending artery of the neck; 47 - spinal branches; 48 - internal carotid artery; 49 - ascending pharyngeal artery; 50 - posterior ear artery; 51 - awl-mastoid artery; 52 - maxillary artery; 53 - occipital artery; 54 - mastoid branch; 55 - transverse artery of the face; 56 - deep ear artery; 57 - occipital branch; 58 - anterior tympanic artery; 59 - masticatory artery; 60 - superficial temporal artery; 61 - anterior ear branch; 62 - middle temporal artery; 63 - middle meningeal artery artery; 64 - parietal branch; 65 - frontal branch
Here, the external jugular vein, piercing the second and third fascia of the neck, goes deep and flows into the subclavian or internal jugular vein.
The large ear nerve runs along with the external jugular vein posterior to it. It innervates the skin of the mandibular fossa and the angle of the mandible. The transverse nerve of the neck (n. transversus colli) crosses the middle of the outer surface of the sternocleidomastoid muscle and at its anterior edge is divided into the upper and lower branches.
The second fascia of the neck forms an isolated case for the sternocleidomastoid muscle. The muscle is innervated by the external branch of the accessory nerve (n. accessories). Inside the fascial case of the sternocleidomastoid muscle, along its posterior edge, the small occipital nerve (n. Occipitalis minor) rises up, innervating the skin of the mastoid process.
Behind the muscle and its fascial sheath is the carotid neurovascular bundle, surrounded by the parietal layer of the fourth fascia of the neck. Inside the bundle, the common carotid artery is located medially, the internal jugular vein - laterally, the vagus nerve - between them and behind.
Rice. 12.11.Veins of the neck (from: Sinelnikov R.D., 1979)
1 - parietal veins-graduates; 2 - superior sagittal sinus; 3 - cavernous sinus; 4 - supratrochlear vein; 5 - naso-frontal vein; 6 - superior ophthalmic vein; 7 - external vein of the nose; 8 - angular vein; 9 - pterygoid venous plexus; 10 - facial vein; 11 - superior labial vein; 12 - transverse vein of the face; 13 - pharyngeal vein; 14 - lingual vein; 15 - lower labial vein; 16 - mental vein; 17 - hyoid bone; 18 - internal jugular vein; 19 - superior thyroid vein; 20 - front
jugular vein; 21 - lower bulb of the internal jugular vein; 22 - inferior thyroid vein; 23 - right subclavian vein; 24 - left brachiocephalic vein; 25 - right brachiocephalic vein; 26 - internal thoracic vein; 27 - superior vena cava; 28 - suprascapular vein; 29 - transverse vein of the neck; 30 - vertebral vein; 31 - external jugular vein; 32 - deep vein of the neck; 33 - external vertebral plexus; 34 - retromandibular vein; 35 - occipital vein; 36 - mastoid venous graduate; 37 - posterior ear vein; 38 - occipital venous graduate; 39 - superior bulb of the internal jugular vein; 40 - sigmoid sinus; 41 - transverse sinus; 42 - occipital sinus; 43 - lower stony sinus; 44 - sinus drain; 45 - superior stony sinus; 46 - direct sine; 47 - a large vein of the brain; 48 - superficial temporal vein; 49 - lower sagittal sinus; 50 - crescent of the brain; 51 - diploic veins
The cervical sympathetic trunk (truncus sympathicus) is located parallel to the common carotid artery under the fifth fascia, but deeper and medial.
Branches of the cervical plexus (plexus cervicalis) emerge from under the sternocleidomastoid muscle. It is formed by the anterior branches of the first 4 cervical spinal nerves, lies on the side of the transverse processes of the vertebrae between the vertebral (back) and prevertebral (front) muscles. The branches of the plexus include:
Small occipital nerve (n. occipitalis minor), extends upward to the mastoid process and further into the lateral parts of the occipital region; innervates the skin of this area;
The large ear nerve (n.auricularis magnus) goes up and anteriorly along the anterior surface of the sternocleidomastoid muscle, covered by the second fascia of the neck; innervates the skin of the auricle and the skin above the parotid salivary gland;
The transverse nerve of the neck (n. transversus colli), goes anteriorly, crossing the sternocleidomastoid muscle, at its anterior edge it is divided into upper and lower branches that innervate the skin of the anterior region of the neck;
Supraclavicular nerves (nn. supraclaviculares), in the amount of 3-5, spread fan-shaped downwards between the first and second fascia of the neck, branch in the skin of the posterior lower part of the neck (lateral branches) and the upper anterior surface of the chest to the III rib (medial branches);
The phrenic nerve (n. phrenicus), predominantly motor, goes down the anterior scalene muscle into the chest cavity, where it passes to the diaphragm in front of the roots of the lungs between
mediastinal pleura and pericardium; innervates the diaphragm, gives off sensitive branches to the pleura and pericardium, sometimes to the cervicothoracic nerve plexus;
The lower root of the cervical loop (r.inferior ansae cervicalis) goes anteriorly to the connection with the upper root arising from the hypoglossal nerve;
Muscular branches (rr. musculares) go to the vertebral muscles, the muscle that lifts the scapula, the sternocleidomastoid and trapezius muscles.
Between the deep (posterior) surface of the lower half of the sternocleidomastoid muscle with its fascial case and the anterior scalene muscle, covered with the fifth fascia, a prescalene space (spatium antescalenum) is formed. Thus, the prescalene space is limited in front by the second and third fascia, and in the back by the fifth fascia of the neck. The carotid neurovascular bundle is located medially in this space. The internal jugular vein lies here not only lateral to the common carotid artery, but also somewhat anterior (more superficial). Here, its bulb (lower extension; bulbus venae jugularis inferior) connects to the subclavian vein that is suitable from the outside. The vein is separated from the subclavian artery by the anterior scalene muscle. Immediately outward from the confluence of these veins, called Pirogov's venous angle, the external jugular vein flows into the subclavian vein. On the left, the thoracic (lymphatic) duct flows into the venous angle. United v. jugularis intema and v. subclavia give rise to the brachiocephalic vein. The suprascapular artery (a. suprascapularis) also passes through the pre-scalene gap in the transverse direction. Here, on the anterior surface of the anterior scalene muscle, under the fifth fascia of the neck, the phrenic nerve passes.
Behind the anterior scalene muscle under the fifth fascia of the neck is the interstitial space (spatium interscalenum). The interscalene space behind is limited by the middle scalene muscle. In the interscalene space, the trunks of the brachial plexus pass from above and laterally, below - a. subclavia.
The stair-vertebral space (triangle) is located behind the lower third of the sternocleidomastoid muscle, under the fifth fascia of the neck. Its base is the dome of the pleura, the apex is the transverse process of the VI cervical vertebra. Posteriorly and medially it is limited by the spine
lump with the long muscle of the neck, and in front and laterally - by the medial edge of the anterior scalene muscle. Under the prevertebral fascia is the contents of the space: the beginning of the cervical subclavian artery with branches extending from it here, the arch of the thoracic (lymphatic) duct, ductus thoracicus (left), the lower and cervicothoracic (stellate) nodes of the sympathetic trunk.
Topography of vessels and nerves. The subclavian arteries are located under the fifth fascia. The right subclavian artery (a. subclavia dextra) departs from the brachiocephalic trunk, and the left (a. subclavia sinistra) - from the aortic arch.
The subclavian artery is conditionally divided into 4 sections:
Thoracic - from the place of discharge to the medial edge (m. scalenus anterior);
Interstitial, corresponding to the interstitial space (spatium interscalenum);
Supraclavicular - from the lateral edge of the anterior scalene muscle to the clavicle;
Subclavian - from the collarbone to the upper edge of the pectoralis minor muscle. The last section of the artery is already called the axillary artery, and it is studied in the subclavian region in the clavicular-thoracic triangle (trigonum clavipectorale).
In the first section, the subclavian artery lies on the dome of the pleura and is connected with it by connective tissue cords. On the right side of the neck anterior to the artery is Pirogov's venous angle - the confluence of the subclavian vein and the internal jugular vein. On the anterior surface of the artery, the vagus nerve descends transversely to it, from which the recurrent laryngeal nerve departs here, enveloping the artery from below and behind and rising upward in the angle between the trachea and esophagus. Outside of the vagus nerve, the artery crosses the right phrenic nerve. Between the vagus and phrenic nerves is the subclavian loop of the sympathetic trunk (ansa subclavia). The right common carotid artery passes medially from the subclavian artery.
On the left side of the neck, the first section of the subclavian artery lies deeper and is covered by the common carotid artery. Anterior to the left subclavian artery is the internal jugular vein and the origin of the left brachiocephalic vein. Between these veins and the artery are the vagus and left phrenic nerves. Medial to the subclavian artery are the esophagus and trachea, and in the groove between them is the left
recurrent laryngeal nerve. Between the left subclavian and common carotid arteries, bending around the subclavian artery behind and above, the thoracic lymphatic duct passes.
Branches of the subclavian artery (Fig. 12.13). The vertebral artery (a. vertebralis) departs from the upper semicircle of the subclavian medially to the inner edge of the anterior scalene muscle. Rising upward between this muscle and the outer edge of the long muscle of the neck, it enters the opening of the transverse process of the VI cervical vertebra and further upwards in the bone canal formed by the transverse processes of the cervical vertebrae. Between the 1st and 2nd vertebrae, it exits the canal. Further, the vertebral artery enters the cranial cavity through the large
Rice. 12.13.Branches of the subclavian artery:
1 - internal thoracic artery; 2 - vertebral artery; 3 - thyroid trunk; 4 - ascending cervical artery; 5 - lower thyroid artery; 6 - lower laryngeal artery; 7 - suprascapular artery; 8 - costocervical trunk; 9 - deep cervical artery; 10 - the uppermost intercostal artery; 11 - transverse artery of the neck
hole. In the cranial cavity at the base of the brain, the right and left vertebral arteries merge into one basilar artery (a. basilaris), which is involved in the formation of the circle of Willis.
Internal thoracic artery, a. thoracica interna, is directed downward from the lower semicircle of the subclavian artery opposite the vertebral artery. Passing between the dome of the pleura and the subclavian vein, it descends to the posterior surface of the anterior chest wall.
The thyroid trunk (truncus thyrocervicalis) departs from the subclavian artery at the medial edge of the anterior scalene muscle and gives off 4 branches: the lower thyroid (a. thyroidea inferior), the ascending cervical (a. cervicalis ascendens), the suprascapular (a. suprascapularis) and the transverse artery of the neck ( a. transversa colli).
A. thyroidea inferior, rising upward, forms an arc at the level of the transverse process of the VI cervical vertebra, crossing the vertebral artery lying behind and the common carotid artery passing in front. From the lower medial part of the arch of the inferior thyroid artery, branches depart to all organs of the neck: rr. pharyngei, oesophagei, tracheales. In the walls of the organs and the thickness of the thyroid gland, these branches anastomose with the branches of other arteries of the neck and the branches of the opposite inferior and superior thyroid arteries.
A. cervicalis ascendens goes up the anterior surface of m. scalenus anterior, parallel to n. phrenicus, inside of it.
A. suprascapularis goes to the lateral side, then with the vein of the same name is located behind the upper edge of the clavicle and together with the lower abdomen m. omohyoideus reaches the transverse notch of the scapula.
A. transversa colli can originate from both the truncus thyrocervicalis and the subclavian artery. The deep branch of the transverse artery of the neck, or dorsal artery of the scapula, lies in the cellular space of the back at the medial edge of the scapula.
Costocervical trunk (truncus costocervicalis) most often departs from the subclavian artery. Having passed up the dome of the pleura, it is divided at the spine into two branches: the uppermost - intercostal (a. intercostalis suprema), reaching the first and second intercostal spaces, and the deep cervical artery (a. cervicalis profunda), penetrating into the muscles of the back of the neck.
The cervicothoracic (stellate) node of the sympathetic trunk is located behind the internal
semicircle of the subclavian artery, the vertebral artery medially extending from it. It is formed in most cases from the connection of the lower cervical and first thoracic nodes. Passing to the wall of the vertebral artery, the branches of the stellate ganglion form the periarterial vertebral plexus.
12.7. LATERAL NECK
12.7.1. Scapular-trapezoid triangle
The scapular-trapezoid triangle (trigonum omotrapecoideum) is bounded from below by the scapular-hyoid muscle, in front by the posterior edge of the sternocleidomastoid muscle, and behind by the anterior edge of the trapezius muscle (Fig. 12.14).
Leatherthin and mobile. It is innervated by the lateral branches of the supraclavicular nerves (nn. supraclaviculares laterals) from the cervical plexus.
Subcutaneous adipose tissue loose.
The superficial fascia contains the fibers of the superficial muscle of the neck. Under the fascia are skin branches. The external jugular vein (v. jugularis externa), crossing from top to bottom and outwards the middle third of the sternocleidomastoid muscle, exits to the lateral surface of the neck.
The superficial sheet of the own fascia of the neck forms a vagina for the trapezius muscle. Between it and the deeper prevertebral fascia is the accessory nerve (n. accessorius), which innervates the sternocleidomastoid and trapezius muscles.
The brachial plexus (plexus brachialis) is formed by the anterior branches of the 4 lower cervical spinal nerves and the anterior branch of the first thoracic spinal nerve.
In the lateral triangle of the neck is the supraclavicular part of the plexus. It consists of three trunks: upper, middle and lower. The upper and middle trunks lie in the interstitial fissure above the subclavian artery, and the lower trunk lies behind it. Short branches of the plexus depart from the supraclavicular part:
The dorsal nerve of the scapula (n. dorsalis scapulae) innervates the muscle that lifts the scapula, the large and small rhomboid muscles;
The long thoracic nerve (n. thoracicus longus) innervates the serratus anterior;
The subclavian nerve (n. subclavius) innervates the subclavian muscle;
The subscapular nerve (n. subscapularis) innervates the large and small round muscles;
Rice. 12.14.Topography of the lateral triangle of the neck:
1 - Sternocleidomastoid muscle; 2 - trapezius muscle, 3 - subclavian muscle; 4 - anterior scalene muscle; 5 - middle scalene muscle; 6 - posterior scalene muscle; 7 - subclavian vein; 8 - internal jugular vein; 9 - thoracic lymphatic duct; 10 - subclavian artery; 11 - thyroid trunk; 12 - vertebral artery; 13 - ascending cervical artery; 14 - lower thyroid artery; 15 - suprascapular artery; 16 - superficial cervical artery; 17 - suprascapular artery; 18 - cervical plexus; 19 - phrenic nerve; 20 - brachial plexus; 19 - accessory nerve
Thoracic nerves, medial and lateral (nn. pectorales medialis et lateralis) innervate the large and small pectoral muscles;
The axillary nerve (n.axillaris) innervates the deltoid and small round muscles, the capsule of the shoulder joint and the skin of the outer surface of the shoulder.
12.7.2. Scapular-clavicular triangle
In the scapular-clavicular triangle (trigonum omoclavicularis), the lower border is the clavicle, the anterior is the posterior edge of the sternocleidomastoid muscle, the upper-posterior border is the projection line of the lower abdomen of the scapular-hyoid muscle.
Leatherthin, mobile, innervated by supraclavicular nerves from the cervical plexus.
Subcutaneous adipose tissue loose.
The superficial fascia of the neck contains fibers of the subcutaneous muscle of the neck.
The superficial sheet of the own fascia of the neck is attached to the anterior surface of the clavicle.
A deep sheet of the own fascia of the neck forms a fascial sheath for the scapular-hyoid muscle and is attached to the posterior surface of the clavicle.
Adipose tissue is located between the third fascia of the neck (in front) and the prevertebral fascia (rear). It spreads in the gap: between the 1st rib and the clavicle with the subclavian muscle adjacent from below, between the clavicle and sternocleidomastoid muscle in front and the anterior scalene muscle behind, between the anterior and middle scalene muscle.
The neurovascular bundle is represented by the subclavian vein (v. subclavia), which is located most superficially in the prescalene space. Here it merges with the internal jugular vein (v. jugularis interna), and also receives the anterior and external jugular and vertebral veins. The walls of the veins of this area are fused with the fascia, therefore, when injured, the vessels gape, which can lead to an air embolism with a deep breath.
The subclavian artery (a. subclavia) lies in the interstitial space. Behind it is the posterior bundle of the brachial plexus. The upper and middle bundles are located above the artery. The artery itself is divided into three sections: before entering the interscalene
space, in the interstitial space, at the exit from it to the edge of the 1st rib. Behind the artery and the lower bundle of the brachial plexus is the dome of the pleura. In the prescalene space, the phrenic nerve passes (see above), crossing the subclavian artery in front.
The thoracic duct (ductus thoracicus) flows into the venous jugular angles, formed by the confluence of the internal jugular and subclavian veins, and the right lymphatic duct (ductus lymphaticus dexter) flows to the right.
The thoracic duct, leaving the posterior mediastinum, forms an arc on the neck, rising to the VI cervical vertebra. The arc goes to the left and forward, is located between the left common carotid and subclavian arteries, then between the vertebral artery and the internal jugular vein and before flowing into the venous angle forms an extension - the lymphatic sinus (sinus lymphaticus). The duct can flow both into the venous angle and into the veins that form it. Sometimes, before confluence, the thoracic duct breaks into several smaller ducts.
The right lymphatic duct has a length of up to 1.5 cm and is formed from the confluence of the jugular, subclavian, internal thoracic and bronchomediastinal lymphatic trunks.
12.8. TESTS
12.1. The composition of the anterior region of the neck includes three paired triangles from the following:
1. Scapular-clavicular.
2. Shoulder-tracheal.
3. Scapular-trapezoid.
4. Submandibular.
5. Sleepy.
12.2. The composition of the lateral region of the neck includes two triangles from the following:
1. Scapular-clavicular.
2. Shoulder-tracheal.
3. Scapular-trapezoid.
4. Submandibular.
5. Sleepy.
12.3. The sternocleidomastoid region is located between:
1. Front and back of the neck.
2. Anterior and lateral region of the neck.
3. Lateral and back region of the neck.
12.4. The submandibular triangle is limited:
1. Top.
2. Front.
3. Back and bottom.
A. The posterior belly of the digastric muscle. B. The edge of the lower jaw.
B. Anterior belly of digastric muscle.
12.5. The sleepy triangle is limited:
1. Top.
2. Bottom.
3. Behind.
A. Upper abdomen of the scapular-hyoid muscle. B. The sternocleidomastoid muscle.
B. Posterior belly of the digastric muscle.
12.6. The scapular-tracheal triangle is limited:
1. Medially.
2. Above and laterally.
3. From below and laterally.
A. The sternocleidomastoid muscle.
B. The upper abdomen of the scapular-hyoid muscle.
B. Midline of the neck.
12.7. Determine the sequence of location from the surface to the depth of 5 fasciae of the neck:
1. Intracervical fascia.
2. Scapular-clavicular fascia.
3. Superficial fascia.
4. Prevertebral fascia.
5. Own fascia.
12.8. Within the submandibular triangle, there are two fascia of the following:
1. Superficial fascia.
2. Own fascia.
4. Intracervical fascia.
5. Prevertebral fascia.
12.9. Within the carotid triangle, there are 4 fascia of the following:
1. Superficial fascia.
2. Own fascia.
3. Scapular-clavicular fascia.
4. Parietal sheet of the intracervical fascia.
5. Visceral sheet of the intracervical fascia.
6. Prevertebral fascia.
12.10. Within the scapular-tracheal triangle, there are the following fasciae from those listed:
1. Superficial fascia.
2. Own fascia.
3. Scapular-clavicular fascia.
4. Intracervical fascia.
5. Prevertebral fascia.
12.11. Within the scapular-trapezoid triangle there are 3 fascia of the following:
1. Superficial fascia.
2. Own fascia.
3. Scapular-clavicular fascia.
4. Intracervical fascia.
5. Prevertebral fascia.
12.12. Within the scapular-clavicular triangle there are 4 fascia of the following:
1. Superficial fascia.
2. Own fascia.
3. Scapular-clavicular fascia.
4. Intracervical fascia.
5. Prevertebral fascia.
12.13. The submandibular salivary gland is located in the fascial bed formed by:
1. Superficial fascia.
2. Own fascia.
3. Scapular-clavicular fascia.
4. Intracervical fascia.
5. Prevertebral fascia.
12.14. In a patient with cancer of the lower lip, a metastasis was found in the submandibular salivary gland, which was the result of metastasis of cancer cells:
1. Through the excretory duct of the gland.
2. Along the tributaries of the facial vein, into which venous blood flows from both the lower lip and the gland.
3. Through the lymphatic vessels of the gland through the lymph nodes located near the gland.
4. Through the lymphatic vessels to the lymph nodes located in the substance of the gland.
12.15. When removing the submandibular salivary gland, a complication is possible in the form of severe bleeding due to damage to the artery adjacent to the gland:
1. Ascending pharyngeal.
2. Facial.
3. Submental.
4. Lingual.
12.16. The suprasternal interaponeurotic space is located between:
1. Superficial and own fasciae of the neck.
2. Own and scapular-clavicular fascia.
3. Scapular-clavicular and intracervical fascia.
4. Parietal and visceral sheets of the intracervical fascia.
12.17. In the fatty tissue of the suprasternal interaponeurotic space are located:
1. Left brachiocephalic vein.
2. External jugular vein.
4. Jugular venous arch.
12.18. Performing a lower tracheostomy, the surgeon, passing the suprasternal interaponeurotic space, must beware of damage to:
1. Arterial vessels.
2. Venous vessels.
3. Vagus nerve.
4. Phrenic nerve.
5. Esophagus.
12.19. The previsceral space is located between:
2. Scapular-clavicular and intracervical fascia.
4. Intracervical and prevertebral fascia.
12.20. The retrovisceral space is located between:
3. Prevertebral fascia and spine.
12.21. A seriously ill patient with purulent posterior mediastinitis as a complication of pharyngeal abscess was delivered to the hospital. Determine the anatomical pathway for the spread of purulent infection into the mediastinum:
1. Suprasternal interaponeurotic space.
2. Previsceral space.
3. Prevertebral space.
4. Retrovisceral space.
5. Vascular-nervous sheath.
12.22. The pretracheal space is located between:
1. Own and scapular-clavicular fascia.
2. The scapular-clavicular fascia and the parietal leaf of the intracervical fascia.
3. Parietal and visceral sheets of the intracervical fascia.
4. Intracervical and prevertebral fascia.
12.23. When performing a lower tracheostomy by median access after penetration into the pretracheal space, severe bleeding suddenly occurred. Identify the damaged artery:
1. Ascending cervical artery.
2. Inferior laryngeal artery.
3. Inferior thyroid artery.
4. Inferior thyroid artery.
12.24. In the pretracheal space there are two of the following formations:
1. Internal jugular veins.
2. Common carotid arteries.
3. Unpaired thyroid venous plexus.
4. Inferior thyroid arteries.
5. Inferior thyroid artery.
6. Anterior jugular veins.
12.25. Behind the larynx are adjacent:
1. Throat.
2. Share of the thyroid gland.
3. Parathyroid glands.
4. Esophagus.
5. Cervical spine.
12.26. To the side of the larynx are two anatomical formations of the following:
1. Sternohyoid muscle.
2. Sternothyroid muscle.
3. Share of the thyroid gland.
4. Parathyroid glands.
5. Isthmus of the thyroid gland.
6. Thyrohyoid muscle.
12.27. In front of the larynx there are 3 anatomical formations of the following:
1. Throat.
2. Sternohyoid muscle.
3. Sternothyroid muscle.
4. Share of the thyroid gland.
5. Parathyroid glands.
6. Isthmus of the thyroid gland.
7. Thyrohyoid muscle.
12.28. In relation to the cervical spine, the larynx is located at the level of:
12.29. The sympathetic trunk on the neck is located between:
1. Parietal and visceral sheets of the intracervical fascia.
2. Intracervical and prevertebral fascia.
3. Prevertebral fascia and long muscle of the neck.
12.30. The vagus nerve, being in the same fascial sheath with the common carotid artery and the internal jugular vein, is located in relation to these blood vessels:
1. Medial to the common carotid artery.
2. Lateral to the internal jugular vein.
3. Anteriorly between artery and vein.
4. Behind between artery and vein.
5. Anterior to the internal jugular vein.
12.31. The paired muscles located in front of the trachea include two of the following:
1. Sternocleidomastoid.
2. Sternohyoid.
3. Sternothyroid.
4. Scapular-hyoid.
5. Thyrohyoid.
12.32. The cervical part of the trachea contains:
1. 3-5 cartilage rings.
2. 4-6 cartilage rings.
3. 5-7 cartilage rings.
4. 6-8 cartilage rings.
5. 7-9 cartilaginous rings.
12.33. Within the neck, the esophagus is closely adjacent to the posterior wall of the trachea:
1. Strictly along the median line.
2. Speaking somewhat to the left.
3. Speaking somewhat to the right.
12.34. The parathyroid glands are located:
1. On the fascial sheath of the thyroid gland.
2. Between the fascial sheath and the capsule of the thyroid gland.
3. Under the capsule of the thyroid gland.
12.35. With subtotal resection of the thyroid gland, the part of the gland containing the parathyroid glands should be left. Such part are:
1. Upper pole of the lateral lobes.
2. The posterior part of the lateral lobes.
3. The posterior part of the lateral lobes.
4. Anterior part of the lateral lobes.
5. Anterolateral part of the lateral lobes.
6. Lower pole of the lateral lobes.
12.36. During a strumectomy operation performed under local anesthesia, when applying clamps to the blood vessels of the thyroid gland, the patient developed hoarseness due to:
1. Violations of the blood supply to the larynx.
2. Compression of the superior laryngeal nerve.
3. Compression of the recurrent laryngeal nerve.
12.37. In the main neurovascular bundle of the neck, the common carotid artery and the internal jugular vein are located relative to each other as follows:
1. The artery is more medial, the vein is more lateral.
2. The artery is more lateral, the vein is more medial.
3. Artery in front, vein in the back.
4. Artery behind, vein in front.
12.38. The victim has severe bleeding from the deep parts of the neck. In order to ligate the external carotid artery, the surgeon exposed in the carotid triangle the place of division of the common carotid artery into external and internal. Determine the main feature by which these arteries can be distinguished from each other:
1. The internal carotid artery is larger than the external one.
2. The beginning of the internal carotid artery is located deeper and outside the beginning of the external.
3. Lateral branches depart from the external carotid artery.
12.39. The anterior space is located between:
1. Sternocleidomastoid and anterior scalene muscle.
2. The long muscle of the neck and the anterior scalene muscle.
3. Anterior and middle scalenus.
12.40. In the preglacial period pass:
1. Subclavian artery.
2. Subclavian vein.
3. Brachial plexus.
4. Vertebral artery.
12.41. Directly behind the collarbone are:
1. Subclavian artery.
2. Subclavian vein.
3. Brachial plexus.
12.42. The interstitial space is located between:
1. Anterior and middle scalene muscles.
2. Middle and posterior scalene muscles.
3. Scalene muscles and spine.
12.43. In relation to the phrenic nerve, the following statements are correct:
1. It is located on the sternocleidomastoid muscle above its own fascia.
2. It is located on the sternocleidomastoid muscle under its own fascia.
3. It is located on the anterior scalene muscle over the prevertebral fascia.
4. Located on the anterior scalene muscle under the prevertebral fascia.
5. It is located on the middle scalene muscle over the prevertebral fascia.
6. It is located on the middle scalene muscle under the prevertebral fascia.
12.44. In the interstitial space pass:
1. Subclavian artery and vein.
2. Subclavian artery and brachial plexus.
(trigonum omotrapezoideum) part of the lateral region of the neck, bounded from below by the scapular-hyoid, behind - by the trapezius and in front - by the sternocleidomastoid muscles.
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Scapular-trapezoid triangle ( trigonum omotrapezoideum) is limited on the upper inner side by the posterior edge of the sternocleidomastoid muscle ( m. sternocleidomastoideus); from the lower inner side - the lower abdomen of the scapular-hyoid muscle ( venter inferior m. omohyoidei), behind - the front edge of the trapezius muscle ( m. trapezius).
Within the scapular-trapezoid triangle behind the middle of the sternocleidomastoid muscle, sensitive branches of the cervical plexus emerge from the inside to the fatty deposits: the large ear nerve ( n. auricularis magnus), going up to the region of the outer ear and mastoid process; medial, intermediate and lateral supraclavicular nerves ( nn. supraclaviculares mediales, intermedii et laterales), heading down through the collarbone within the subclavian region; lesser occipital nerve ( n. occipitalis minor), going back and up to the occipital region; transverse nerve of the neck ( n. transverse colli), passing in the transverse direction to the midline of the neck (Fig. 7-11 ).
In the scapular-trapezoid triangle produce:
1 ) vagosympathetic blockade;
2 a) anesthesia of the cervical plexus;
3 ) access to the esophagus. The incision is made behind the left sternocleidomastoid muscle with pulling it anteriorly, after which the cervical part of the esophagus is exposed.
4 ) cuts ( incisions) with deep phlegmon of the neck resulting from injury or perforation of the esophageal wall by a foreign body.
The lower abdomen of the scapular-hyoid muscle divides the lateral triangle into a larger one (trigonum omotrapezoideum) and a smaller one (trigonum omoclaviculare). The last triangle corresponds to a large supraclavicular fossa, fossa supraclavicularis major. The skin is thin and mobile. M. platysma covers only the anteroinferior section of the triangle. In the subcutaneous tissue are the middle, intermediate and lateral supraclavicular nerves, nn. supraclaviculares mediales, intermedii et laterales, branches of the cervical plexus that innervate the skin of the neck and shoulder girdle. Along the posterior edge of the sternocleidomastoid muscle, the small occipital nerve, n. occipitalis minor. Above m. omohyoideus there are two fasciae of the neck - own (II) and prevertebral (V). Below m. omohyoideus behind the second fascia of the neck are the scapular-clavicular (III) fascia of the neck, and behind it is the fifth fascia, which forms cases for the scalene muscles here and attaches with them to the 1st and 2nd ribs, as well as the vagina for the subclavian artery and trunks of the brachial plexus. In the trigonum omotrapezoideum passes the accessory nerve, n. accessorius, which innervates the sternocleidomastoid and trapezius muscles. Between the anterior and middle scalene muscles, the cervical and brachial plexuses, plexus cervicalis and plexus brachialis, are formed. In the trigonum omoclaviculare pass the third section of the subclavian artery and the supraclavicular part of the plexus brachialis. There are three arteries in the scapular-clavicular triangle: a.suprascapularis, a.cervicalis superficialis and a.transversa colli. The lower edge of the artery covers the subclavian vein, v.subclavia. In the lateral triangle of the neck there are three groups of lymph nodes: along the accessory nerve, the superficial cervical artery, and the supraclavicular group, located along the suprascapular artery. The supraclavicular lymph nodes are associated with the subclavian. Lymph flows here from the tissues of the lateral triangle of the neck, and from the mammary gland, as well as from the organs of the chest cavity.
Operative access to the subclavian artery. Puncture and catheterization of the subclavian vein: indications, technique, complications.
Operative access to the subclavian arteries: Access to the artery above the clavicle. When ligating an artery or suturing it above the clavicle, an incision is made 8-10 cm long, 1 cm above the clavicle, which reaches the outer edge of the sternocleidomastoid muscle. The tissue is dissected in layers. It is necessary to strive to manipulate the rib in order to avoid injury to the dome of the pleura and the thoracic duct. The exposed artery is isolated, a Deschamp needle is placed under it, ligated and cut between two ligatures. The central segment should be stitched and tied with two ligatures. The wound is sutured.
Access to the artery under the clavicle. When ligating the artery under the clavicle, an incision up to 8 cm long is made parallel to the lower edge of the clavicle and 1 cm below. The tissues are dissected in layers. They bluntly penetrate the adipose tissue until they find the inner edge of the pectoralis minor muscle, under which the artery is located. With the help of a Deschamps needle, strong ligatures are brought in, tied, and an artery is cut between them. subclavian vein starts from the lower border of the 1st rib, goes around it from above, deviates inwards, down and slightly forward at the point of attachment to the 1st rib of the anterior scalene muscle and enters the chest cavity. Behind the sternoclavicular joint, they connect with the internal jugular vein and form the brachiocephalic vein, which forms the superior vena cava in the mediastinum with the left side of the same name. In front of the PV is the clavicle. The highest point of the PV is anatomically determined at the level of the middle of the clavicle in its upper border.
Laterally from the middle of the clavicle, the vein is located anterior and inferior to the subclavian artery. Medially behind the vein there are bundles of the anterior scalene muscle, the subclavian artery and, then, the dome of the pleura, which rises above the sternal end of the clavicle. The PV passes anterior to the phrenic nerve. On the left, the thoracic lymphatic duct flows into the brachiocephalic vein.
Puncture and catheterization of the subclavian vein:
INDICATIONS for catheterization can be: Inaccessibility of peripheral veins for infusion therapy; long-term operations with large blood loss; the need for multi-day and intensive therapy; the need for parenteral nutrition, including the transfusion of concentrated, hypertonic solutions; the need for diagnostic and control studies (measurement of central venous pressure in the cavities of the heart, radiopaque studies, multiple blood sampling, etc.).
CONTRAINDICATIONS to PV catheterization are: Sharp disturbances of the blood coagulation system in the direction of hypocoagulation; local inflammatory processes in the places of vein catheterization; severe respiratory failure with emphysema; bilateral pneumothorax; collarbone injury. With unsuccessful CPV or its impossibility, the internal and external jugular or femoral veins are used for catheterization.
Catheterization technique: The room where the CPV is performed should be with a sterile operating room: a dressing room, an intensive care unit or an operating room. In preparation for CPV, the patient is placed on the operating table with the head end lowered by 15° to prevent air embolism. The head is turned in the direction opposite to the punctured one, the arms are extended along the body. In sterile conditions, a table with tools is laid. The doctor washes his hands as before a normal operation, puts on gloves. The operating field is treated twice with a 2% iodine solution, covered with a sterile diaper and once again treated with 70 ° alcohol. Subclavian access With a syringe with a thin needle, 0.5% solution of procaine is injected intradermally to create a "lemon peel" at a point located 1 cm below the collarbone on the line separating the middle and inner third of the clavicle. The needle is advanced medially towards the upper edge of the sternoclavicular joint, continuously prescribing a solution of procaine. The needle is passed under the collarbone and the rest of the procaine is injected there. The needle is removed. With a thick sharp needle, limiting the depth of its insertion with the index finger, the skin is pierced to a depth of 1–1.5 cm at the location of the “lemon peel”. The needle is removed. In a syringe with a capacity of 20 ml, half is filled with 0.9% sodium chloride solution, a not very sharp (to avoid puncture of the artery) needle 7–10 cm long with a bluntly beveled end is put on. The direction of the bevel should be marked on the cannula. When inserting the needle, its bevel should be oriented in the caudal-medial direction. The needle is inserted into a puncture previously made with a sharp needle (see above), while the depth of the possible insertion of the needle should be limited by the index finger (no more than 2 cm). The needle is advanced medially towards the upper edge of the sternoclavicular joint, periodically pulling the piston back, checking the flow of blood into the syringe. If unsuccessful, the needle is advanced back without removing it completely, and the attempt is repeated, changing the direction of advance by several degrees. As soon as blood appears in the syringe, some of it is injected back into the vein and sucked back into the syringe, trying to get a reliable backflow of blood. If a positive result is obtained, the patient is asked to hold his breath and remove the syringe from the needle, pinching its hole with a finger. A conductor is inserted into the needle with light screwing movements up to half, its length is slightly more than two times the length of the catheter. The patient is again asked to hold his breath, the conductor is removed, closing the catheter hole with a finger, then a rubber stopper is put on the latter. After that, the patient is allowed to breathe. If the patient is unconscious, all manipulations related to the depressurization of the lumen of the needle or catheter located in the subclavian vein are performed during exhalation. The catheter is connected to the infusion system and fixed to the skin with a single silk suture. Apply an aseptic bandage.
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Layers of the scapular-trapezoid triangle. Arteries in the region of the scapular-trapezoid triangle. Nerves in the region of the scapular-trapezoid triangle.
Skin in the area of the scapular-trapezoid triangle thin, mobile.
In the subcutaneous tissue in the region of the scapular-trapezoid triangle there are branches of the cervical plexus - supraclavicular nerves, nn. supraclaviculares, innervating the skin of the neck and shoulder girdle.
The superficial fascia covers entire scapular-trapezoid triangle. Platysma covers only the anteroinferior section of the triangle.
The next layer, as in all other triangles, is the superficial plate of the fascia of the neck (2nd fascia). Neither the 3rd nor the 4th fascia is present in this triangle.
In the tissue in the region of the scapular-trapezoid triangle between the 2nd and 5th fascia passes the accessory nerve, n. accessorius, which innervates the sternocleidomastoid and trapezius muscles.
From under the sternocleidomastoid muscle the transverse superficial cervical artery and vein also exit. These vessels, as well as the accessory nerve, lie on the 5th fascia. In the same layer, along the accessory nerve, there are lymph nodes that collect lymph from the tissues of the lateral region of the neck.
5th, prevertebral, fascia covers the anterior and middle scalene muscles in the area of the scapular-trapezoid triangle. Between these muscles, the cervical and brachial plexuses, plexus cervicalis and plexus brachialis, also lying under the 5th fascia, are formed.
SPADE-TRAPEZIOID TRIANGLE
(trigonum omotrapezoideum) part of the lateral region of the neck, bounded from below by the scapular-hyoid, behind - by the trapezius and in front - by the sternocleidomastoid muscles.
Medical terms. 2012
See also interpretations, synonyms, meanings of the word and what is a SPADE-TRAPEZIOID TRIANGLE in Russian in dictionaries, encyclopedias and reference books:
- TRIANGLE in the Dictionary of Automotive Jargon:
- emergency sign... - TRIANGLE in the Directory of Constellations, Latin names.
- TRIANGLE in the Big Encyclopedic Dictionary:
- MUSIC TRIANGLE in the Encyclopedic Dictionary of Brockhaus and Euphron:
or triangle - a metal percussion instrument of Eastern origin with an indefinite sonority. Consists of a steel rod bent in the shape of a triangle. By … - TRIANGLE in the Encyclopedic Dictionary of Brockhaus and Euphron.
- TRIANGLE in the Modern Encyclopedic Dictionary:
- TRIANGLE in the Encyclopedic Dictionary:
polygon with 3 sides. Sometimes a triangle is also understood as a part of the plane bounded by the sides of the triangle. If, for any reason, one is singled out ... - TRIANGLE in the Encyclopedic Dictionary:
, -a, m. 1. A geometric figure is a polygon with three corners, as well as any object, a device of this form. Rectangular t... - TRIANGLE
TRIANGLE, self-sounding music. tool-t - a steel bar bent in the form of a triangle, which is hit with a stick. Used in orchestras and instr. ensembles. … - TRIANGLE in the Big Russian Encyclopedic Dictionary:
TRIANGULUM (lat. Triangulum), constellation Sev. hemispheres of the sky; from the territory Russia is best seen in late summer, autumn and… - TRIANGLE in the Big Russian Encyclopedic Dictionary:
TRIANGLE, a part of a plane bounded by three line segments (sides of a T.), having in pairs one common end (vertices of a T.). The sum of all angles... - TRIANGLE in the Encyclopedia of Brockhaus and Efron.
- TRIANGLE
triangular flax, triangular flax, triangular flax, triangular flax, triangular flax, triangular flax, triangular flax, triangular flax, triangular flax, triangular flax, triangular flax, ... - TRAPEZOID in the Full accentuated paradigm according to Zaliznyak:
trape`cievi "bottom, trape`cievi" bottom, trape`cievi "bottom, trape`cievi" bottom, trape`cievi "bottom, trape`cievi" bottom, trape`cievi "bottom, trape`cievi" bottom, trape` tsiev "bottom, trape`tsiev" bottom, trape`tsiev "bottom, trape`tsiev" bottom, trape`tsiev "bottom, trape`tsiev" bottom, trape`tsiev "bottom, trape`tsiev" bottom, trape`tsiev" bottom, trapeze`cievi "bottom, trape`cievi" bottom, trapeze`cievi "days, ... - TRIANGLE in the Dictionary for solving and compiling scanwords:
A ruler with an odd number... - TRIANGLE
tool, polygon, letter, constellation, triangle, … - TRAPEZOID in the dictionary of Synonyms of the Russian language:
trapezoidal, trapezoidal, ... - TRIANGLE
1. m. 1) A geometric figure on a plane, bounded by three intersecting straight lines forming three internal angles .. 2) Any object of such a shape. … - TRAPEZOID in the New explanatory and derivational dictionary of the Russian language Efremova:
adj. Looking reminiscent of… - TRIANGLE
triangle, … - TRIANGLE in the Spelling Dictionary:
triangle, ... - TRAPEZOID in the Spelling Dictionary:
trapezoidal; cr. f. -den, ... - TRIANGLE in the Dictionary of the Russian Language Ozhegov:
The name of the sergeant and foreman insignia of this form on the buttonholes in the Red Army (from 1919 to 1943) Colloq triangle ... - TRIANGLE in the Modern Explanatory Dictionary, TSB:
a part of a plane bounded by three line segments (sides of a triangle) that have one common end in pairs (the vertices of a triangle). The sum of all the angles of a triangle... - TRIANGLE in the Explanatory Dictionary of the Russian Language Ushakov:
and (colloquial) trigon, triangle, m. 1. A geometric figure bounded by three mutually intersecting straight lines forming three internal angles (mat.). Obtuse triangle. … - TRIANGLE
triangle 1. m. 1) A geometric figure on a plane, bounded by three intersecting straight lines forming three internal angles .. 2) Any object such ... - TRAPEZOID in the Explanatory Dictionary of Efremova:
trapezoidal adj. Looking reminiscent of… - TRIANGLE
- TRAPEZOID in the New Dictionary of the Russian Language Efremova:
adj. Looking reminiscent of… - TRIANGLE
I m. 1. A geometric figure on a plane, bounded by three intersecting straight lines forming three internal angles. 2. Any object of this form. … - TRAPEZOID in the Big Modern Explanatory Dictionary of the Russian Language:
adj. ; \u003d trapezius "ideal In appearance resembling a trapezoid [ trapezoid ... - TRIANGLE in the Big Modern Explanatory Dictionary of the Russian Language:
m. Constellation of the Northern ... - VASCULAR TUMORS in the Medical Dictionary:
- VASCULAR TUMORS
Hemangioma is the most common tumor of the head and neck in children. Girls are affected more often than boys. The lesion is usually single. - Types of hemangiomas... - FASCIA in Medical terms:
(f. omoclavicularis) see the list of anat. … - REFLEX SHOULDER-SHOULDER in Medical terms:
(r. scapulobrachialis; syn. ankylosing scapulo-shoulder reflex) physiological P.: bringing the shoulder and rotating it outward when hitting the inner edge with a hammer ... - MUSCLE in Medical terms:
(m. ornohyoideus, pna, bna, jna) see the list of anat. … - SHOULDER-SHOULDER-FACIAL MYOPATHY in Medical terms:
(m. brachioscapulofacialis; syn. landuzi Dejerine form of myopathy) - M., characterized by atrophy of the muscles of the face (myopathic face) and shoulder girdle (symptoms of pterygoid ... - SCOOP-TRACHEAL TRIANGLE in Medical terms:
(trigonum omotracheale) part of the anterior region of the neck, bounded above and laterally by the scapular-hyoid, below and laterally by the sternocleidomastoid muscles, in front by the median ... - Scapular-clavicular triangle in Medical terms:
(trigonum omoclaviculare, pna, jna) part of the lateral region of the neck, bounded below by the clavicle, above - by the scapular-hyoid muscle, in front - by the sternocleidomastoid muscle; place … - LYMPH NODE in Medical terms:
(n. l. juguloomohyoideus, pna) see List of anat. … - BEKHTEREV'S SHOULDER-SHOULDER REFLEX in Medical terms:
(V. M. Bekhterev) see Reflex scapular-brachial ... - LENINGRAD PRODUCTION ASSOCIATION RED TRIANGLE
production association "Red Triangle", the country's largest enterprise for the production of rubber products. Organized in 1962. It includes ... - TRAPEZOID; KR. F. -DEN in the Complete Spelling Dictionary of the Russian Language:
trapezoidal; cr. f. -den, ... - STALKER (MOVIE) at the Wiki Quote.
- Dulcimer in the Ethnographic Dictionary:
(from the Greek kymbalon - cymbal), a stringed percussion and plucked musical instrument. trapezoidal flat body, when playing set on your knees or ... - Dulcimer in the Dictionary of Ethnographic Terms:
(from the Greek kymbalon - cymbal), a stringed percussion and plucked musical instrument. Trapezoidal flat body, when playing set on your knees or ... - THE SEAL OF SOLOMON in the Dictionary Index of Theosophical Concepts to the Secret Doctrine, Theosophical Dictionary:
- The symbolic double triangle adopted by T.O. and many theosophists. Why it should be called the "Seal of Solomon" remains a mystery, unless... - GEOMETRIC SYMBOLS in the Directory of Characters and Cult Objects of Greek Mythology:
a class of mythopoetic signs, identical in form to geometric elements and widely used in the sphere of mythological and religious, as well as more ... - MUSCLE DYSTROPHY in the Medical Dictionary:
- POLYMYALGIA rheumatic in the Medical Dictionary:
- AMIOTROPHY in the Medical Dictionary:
- POLYMYALGIA rheumatic in the Medical Big Dictionary:
Polymyalgia rheumatica is a clinical syndrome of unclear etiology (presumably viral), characterized by soreness and stiffness of the muscles of the shoulder and pelvic girdle, fever, weight loss, ... - MUSCLE DYSTROPHY in the Medical Big Dictionary:
Muscular dystrophies include Duchenne, Dreyfus, Landuzy-Dejerine, Leiden-Mobius and a number of other diseases. Below is a brief description of the most common muscle ... - AMIOTROPHY in the Medical Big Dictionary:
Amyotrophy is a violation of muscle trophism, accompanied by thinning of muscle fibers and a decrease in their contractility, due to damage to the nervous system: motor neurons (by ... - PHARINGOTOMY SUBlingual in Medical terms:
(p. infrahyoidea) F., in which the hyoid bone is exposed with a horizontal incision of the soft tissues at the level of its lower edge, the muscles attached ... - SLEEPING TRIANGLE in Medical terms:
(trigonum caroticum, pna, jna; fossa carotica, bna; trigonum omohyoideum; synonym: poles, hyoid fossa, carotid fossa) section of the anterior region of the neck, limited ... - SUPraclavicular fossa LARGE in Medical terms:
(fossa supraclavicularis major, pna, bna, jna) depression above the clavicle between the edges of the sternocleidomastoid and trapezius muscles; corresponds to the scapular-clavicular ... - HUR in the Great Soviet Encyclopedia, TSB:
morinkhur, Mongolian and Buryat 2-string bowed folk musical instrument. Widespread among nomadic pastoralists. The body is wooden, trapezoidal, painted with national ornaments, with leather … - Michelangelo Buonarroti in the Great Soviet Encyclopedia, TSB:
Buonarroti (Michelangelo Buonarroti; otherwise - Michelangelo di Lodovico di Lionardo di Buonarrto Simoni) (6.3.1475, Caprese, now Caprese-Michelangelo, Tuscany, - 18.2.1564, ...