What is the limit of the sleepy triangle. Sleep triangle. Cellular spaces of the neck
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 the 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 wall of the pharynx 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 the 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
The 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 fatty lump of the neck 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 indicated 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 posterior belly muscle of the digastric muscle starts from the mastoid notch of the temporal bone, the anterior one - 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 sleep 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 outlet of the superior thyroid artery at the level of the large horn of the hyoid bone, directly below the hyoid nerve, on the anterior surface of the external carotid artery, there 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 upwards 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 one (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 the elastic and collagen fibers running in the longitudinal direction, also smooth muscle fibers running in the longitudinal and oblique directions.
From the inside, the trachea is covered with a mucous membrane, in which the most superficial layer is a stratified ciliated cylindrical epithelium. A large number of goblet cells located in this layer, together with the tracheal glands, produce 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 vertebra 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, 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 own capsule of the thyroid
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 an 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 front 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 caroticum
sleepy triangle limited by the posterior belly of the digastric and stylohyoid muscles, the anterior edge of the sternocleidomastoid muscle and the upper belly of the scapular-hyoid muscle.
Skin, subcutaneous tissue, superficial fascia and platysma are built in the same way as in the submandibular region.
Between the first and second cervical fascia at the anterior edge of the sternocleidomastoid muscle are the initial part of the external jugular vein, especially in cases where it is a continuation of the posterior and facial veins, and the connection between the cervical branch of the facial nerve and the branch of the transverse nerve of the neck.
Under the second cervical fascia lies a layer of fatty tissue, which covers the outside of the vessels and nerves of the triangle, wrapped in the fourth fascia of the neck. Of these, the most superficially located are the internal jugular vein, which occupies the upper-posterior part of the triangle, and the facial, retromaxillary, lingual, superior thyroid and pharyngeal veins that flow into it.
The retromaxillary vein is somewhat smaller in about half of the cases, and the facial vein in about one-sixth of all cases drains into the external jugular vein, crossing the carotid triangle between the first and second cervical fasciae. Under the veins lie the upper part of the cervical loop, the hypoglossal nerve, the carotid arteries and their branches.
Located in most cases below (up to 1.5 cm) the posterior belly of the digastric muscle and above the bifurcation of the common carotid artery, the hypoglossal nerve passes arcuately along the lateral surface of the internal and external carotid arteries.
From the descending part of the arch of the hypoglossal nerve at the level of the internal carotid artery, the upper part of the cervical loop departs. It descends along the anterior surface of the internal and then the common carotid artery and, outside the carotid triangle, connects with the lower branch, forming ansa cervicalis, which goes around the internal jugular vein from the outside and gives off branches that innervate the infrahyoid muscles.
Carotid arteries. In most cases, the bifurcation, external and partially internal carotid arteries are located within the carotid triangle. The bifurcation of the common carotid artery in about 50% is at the level of the upper edge of the thyroid cartilage and very often at the level of the hyoid bone or between the hyoid bone and the upper edge of the thyroid cartilage. The relationship of the external and internal carotid arteries is such that at the bifurcation, the internal carotid artery lies behind and laterally from the external one; as it moves away from the bifurcation, the internal carotid artery deviates to the medial side and is already located medially or medially and posteriorly from the external carotid artery.
Rice. 162. The first sheet of the cervical fascia and the subcutaneous muscle of the neck; the head is thrown back and turned in the opposite direction. Side and front view (3/4).
Only the skin has been removed.
However, when ligating the carotid arteries, it should be remembered that in a bifurcation, the internal carotid artery in relation to the external one can be located laterally, posteriorly, posteriorly and medially, and even medially or medially and anteriorly.
In relation to the large veins flowing within the carotid triangle into the internal jugular vein, the bifurcation of the common carotid artery may be higher, at the level (medial), lower, or lie in the gap between the veins.
Rice. 163. The second sheet of the cervical fascia and the veins and nerves located outside of it; the head is thrown back and turned in the opposite direction. Side and front view (3/4).
The first sheet of the cervical fascia and the subcutaneous muscle of the neck are removed.
The superior thyroid artery always departs from the branches of the external carotid artery in the carotid triangle, less often the lingual, facial, occipital and ascending pharyngeal arteries. These arteries sometimes begin with common trunks, forming truncus linguofacialis, truncus thyreolingualis, truncus pharyngooccipitalis, etc. Heading in different directions, the branches of the external carotid artery leave the carotid triangle; the superior thyroid artery goes down to the superior pole of the thyroid gland and hides behind the sternothyroid and scapular-hyoid muscles; the lingual artery goes up and over the hyoid bone goes under the hyoid-lingual muscle; the facial artery goes up between the wall of the pharynx and the posterior belly of the digastric muscle and the awl-hyoid muscle and, rounding them from the inside out, penetrates into the bed of the submandibular gland; the occipital artery goes back and up and lies along the medial surface of the posterior belly of the digastric muscle. The external carotid artery itself leaves the region of the carotid triangle through the gap between the posterior belly of the digastric muscle and the stylohyoid muscle, on the one hand, and the stylohyoid muscle, on the other, and penetrates into the bed of the parotid gland.
Rice. 164. Fascial sheaths, formed by the second and third sheets of the cervical fascia; the head is thrown back and turned in the opposite direction. View
side and front (3/4).
The second and third sheets of the cervical fascia are opened and the submandibular gland, sternocleidomastoid, trapezius, digastric, sternohyoid and scapular-hyoid muscles and the accumulation of fatty tissue in the lateral region of the neck, located under the second sheet of the cervical fascia, are exposed.
In the bifurcation of the common carotid artery, there is a carotid reflexogenic zone containing baro- and chemoreceptors and participating in the regulation of blood pressure and blood chemistry. It consists of an expanded initial part of the internal carotid artery (sinus caroticus),
sleepy tangle (glomus caroticum) and the sinus carotid approaching them from the glossopharyngeal nerve, branches of the vagus and sympathetic nerves. The carotid tangle is shaped like a nodule or a grain of rice and is most often located in the carotid fork or on the posteromedial surface of the initial part of the external carotid artery.
Sinus carotici, approaching the carotid tangle, exchanges communicating branches with the vagus nerve, its pharyngeal branches and the superior laryngeal nerve, and with the superior cervical sympathetic ganglion.
In the lower part of the carotid triangle in front of the common carotid artery in newborns and children, the upper pole of the thyroid lobe is often located, while in adults it is found here only in cases of significant development of the latter.
Between the internal jugular vein and the common and internal carotid arteries, outside the sheath of the vessels, there is a vagus nerve adjacent to the posterolateral surface of the arteries. Along the posteromedial surface of the common and internal carotid arteries, under the prevertebral fascia or in its sheets, there is a sympathetic trunk and an upper cervical sympathetic ganglion.
Rice. 165. Fascial sheaths, formed by the second sheet of the cervical fascia; the head is thrown back and turned in the opposite direction. Side and front view (3/4).
The sternocleidomastoid muscle and submandibular gland have been removed.
Medial to the external and internal carotid arteries from the vagus nerve, the superior laryngeal nerve goes down and forward. Within the limits of the carotid triangle, the upper cardiac nerves depart from the vagus or superior laryngeal nerves and the superior cervical sympathetic ganglion (Mr. cardiaci superiores and n. cardiacus cervicalis superior), which are involved in the formation of cardiac nerve plexuses.
Related content:
Operative surgery: lecture notes I. B. Getman
1. Triangles, fasciae of the neck, vessels, organs of the neck area
The neck is an area whose upper border runs along the lower edge of the lower jaw, the apex of the mastoid process and the upper nuchal line. The lower border corresponds to the jugular notch of the sternum, the upper edges of the clavicles and the line connecting the acromial process of the scapula with the spinous process of the VII cervical vertebra.
In the anterior part of the neck, separated from the posterior frontal plane, there are organs - the trachea, esophagus, thyroid gland, neurovascular bundles, the thoracic duct is located in the cervical vertebrae passing through the transverse processes. In the back of the neck there are only muscles enclosed in dense fascial cases and adjacent to the cervical vertebrae.
Neck triangles. By a horizontal plane drawn at the level of the body of the hyoid bone, the anterior neck is divided into suprahyoid and infrahyoid regions. The muscles located in the suprahyoid region form the bottom of the oral cavity; three triangles are distinguished in this region: an unpaired submental triangle, the sides of which are formed by the hyoid bone and two anterior bellies of the digastric muscles; paired right and left submandibular triangles formed by the lower edge of the lower jaw and both bellies (anterior and posterior) of the digastric muscles. The sublingual region is divided by the median line into the right and left sides. On each side, two large triangles and a rectangle are distinguished.
The medial triangle is formed by the median line, the posterior belly of the digastric muscle, and the anterior edge of the sternocleidomastoid muscle; lateral triangle - the posterior edge of the sternocleidomastoid muscle, the upper edge of the clavicle and the lateral edge of the trapezius muscle. Between these triangles is a rectangle - the sternocleidomastoid region. In the medial triangle, two triangles are formed - the scapular-tracheal and scapular-hyoid (carotid triangle), since the common carotid artery and its bifurcation are located within it.
Fascia of the neck. The clearest description was given by Academician V. N. Shevkunenko, who proposed a classification based on a genetic approach to study.
By origin, all fasciae are divided into three groups:
1) fasciae of connective tissue origin, formed as a result of compaction of loose connective tissue and fiber around muscles, blood vessels and nerves;
2) fascia of muscular origin, formed at the site of reduced muscles or flattened and stretched tendons (aponeurosis);
3) fasciae of coelomic origin, which are formed from the inner lining of the primary embryonic cavity or from the reducing sheets of the primary mesentery.
In this regard, 5 fasciae are distinguished on the neck. The first fascia of the neck - the superficial fascia is of muscular origin, it is found in all parts of the neck. On the front surface of the neck, this fascia can be stratified by accumulations of adipose tissue into several plates. In the anterolateral sections, the superficial fascia forms a case for the subcutaneous muscle and, together with its fibers, continues to the face, and below to the subclavian region. In the back of the neck, numerous connective tissue bridges stretch from the superficial fascia to the skin, dividing the subcutaneous adipose tissue into numerous cells. This feature of the structure of the subcutaneous fat leads to the development of carbuncles in this zone (sometimes), accompanied by extensive necrosis of the fiber, reaching the fascial muscle cases. The second fascia of the neck - a superficial sheet of its own fascia - in the form of a dense sheet surrounds the entire neck, including both its anterior and posterior sections. Around the submandibular gland, sternocleidomastoid, and trapezius muscles, this fascia splits and forms a sheath. The spurs of the second fascia extending in the frontal direction are attached to the transverse processes of the cervical vertebrae and anatomically divide the neck into two sections: anterior and posterior. Due to the presence of a dense fascial plate, purulent processes develop in isolation, either only in the anterior or only in the posterior parts of the neck. The third fascia (deep sheet of the own fascia of the neck) is of muscular origin. It is a thin but dense connective tissue plate stretched between the hyoid bone and the collarbone. At the edges, this fascia is limited by the scapular-subclavian muscles, and near the midline by the so-called "long muscles of the neck" (sternohyoid, sternothyroid, sublingual thyroid) and resembles a trapezoid (or sail) in shape. Unlike the 1st and 2nd fascia, which cover the entire neck, the 3rd fascia has a limited length and covers only the scapular-tracheal, scapular-clavicular triangles and the lower part of the sternocleidomastoid region. The fourth fascia (intracervical) is a derivative of the tissues that form the lining of the primary cavity. This fascia has two sheets: parietal and visceral. The visceral layer covers the organs of the neck: the trachea, esophagus, thyroid gland, forming fascial capsules for them. The parietal layer surrounds the entire complex of organs of the neck and the neurovascular bundle, consisting of the common carotid artery, the internal jugular vein, and the vagus nerve. Between the parietal and visceral sheets of the 4th fascia, anterior to the organs, a slit-like cellular space is formed - previsceral (spatium previscerale, spatium pretracheale). Behind the 4th fascia of the neck, between it and the fifth fascia, there is also a layer of fiber - the retrovisceral (spatium retroviscerale) space. The fourth fascia, surrounding the organs of the neck, topographically does not go beyond the median triangle of the neck and the region of the sternocleidomastoid muscle. In the vertical direction, it continues upward to the base of the skull (along the walls of the pharynx), and descends downward along the trachea and esophagus into the chest cavity, where its analogue is the intrathoracic fascia. From this follows an important practical conclusion about the possibility of spreading (formation of a streak) of a purulent process from the cellular spaces of the neck into the tissue of the anterior and posterior mediastinum with the development of anterior or posterior mediastinitis. The fifth fascia (prevertebral) covers mm. longi colli lying on the anterior surface of the cervical spine. This fascia is of connective tissue origin. Continuing in the lateral direction, it forms a case (fascial sheath) for the brachial plexus with the subclavian artery and vein and reaches the edges of the trapezius muscles. Between the 5th fascia and the anterior surface of the spine, a bone-fibrous sheath is formed, filled mainly with the long muscles of the neck and surrounding them with loose fiber.
Fascial cases often serve as pathways for the spread of hematomas in case of injuries of the blood vessels of the neck and the spread of purulent streaks in case of phlegmon of various localization. Depending on the direction of the fascial sheets, the formation of spurs and connections with bones or neighboring fascial sheets, the cellular spaces of the neck can be divided into two groups: closed cellular spaces and open cellular spaces. Closed cellular spaces are represented by the following formations. Suprasternal interaponeurotic space located between the 2nd and 3rd fascia of the neck; case of the submandibular gland, formed by splitting the 2nd fascia of the neck, one of the sheets of which is attached to the lower edge of the jaw, the second to the linea mylohyoidea; case of the sternocleidomastoid muscle (formed by splitting the 2nd fascia). Unclosed cellular spaces include: the previsceral space located between the parietal and visceral sheets of the 4th fascia in front of the trachea from the level of the hyoid bone to the jugular notch of the sternum (at the level of the sternum handle with a fragile transverse septum, separated from the anterior mediastinum); retrovisceral space (located between the visceral sheet of the 4th fascia, surrounding the pharynx, trachea and esophagus, and the 5th fascia, continues into the posterior mediastinum); fascial sheath of the neurovascular bundles of the neck, formed by the parietal sheet of the 4th fascia (at the top it reaches the base of the skull, and at the bottom it leads to the anterior mediastinum); fascial sheath of the neurovascular bundle, formed in the lateral triangle of the neck by the 5th fascia (penetrates the interstitial space and then goes to the subclavian and axillary regions).
The main principle in the treatment of neck abscesses is a timely incision that provides a wide opening of all pockets in which pus can accumulate. Depending on the localization of the purulent focus, various incisions are used for its drainage. With phlegmon of the suprasternal interaponeurotic cellular space, it is advisable to make an incision along the midline from the jugular notch of the sternum from the bottom up. If the process extends into the supraclavicular interaponeurotic space, counter-opening can be applied by making a transverse incision above the clavicle with the introduction of drainage from the outer edge of the sternocleidomastoid muscle. In severe cases, it is possible to cross one of the legs (sternal or clavicular) of the muscle. With phlegmon of the sac of the submandibular gland, the incision is made parallel to the edge of the lower jaw, 3-4 cm below. After dissection of the skin, subcutaneous tissue and the 1st fascia of the neck, the surgeon penetrates deep into the gland case in a blunt way. The cause of such phlegmon may be carious teeth, the infection of which penetrates into the submandibular lymph nodes. With submental phlegmon, a median incision is made between the two anterior bellies of the digastric muscle. With phlegmon of the vascular sheaths, the incision is made along the anterior edge of the sternocleidomastoid muscle or above the clavicle, parallel to it, from the posterior edge of the sternocleidomastoid muscle to the anterior edge of the trapezius. Phlegmon of the vagina of the sternocleidomastoid muscle is opened with incisions along the anterior or posterior edge of the muscle, opening a sheet of the 2nd fascia, which forms the anterior wall of the muscle sheath. Phlegmon of the previsceral space can be drained by a transverse incision over the jugular notch of the sternum. Phlegmons of the retrovisceral space are opened with an incision along the inner edge of the sternocleidomastoid muscle from the notch of the sternum to the upper edge of the thyroid cartilage. The pharyngeal abscess is opened through the mouth in the zone of greatest fluctuation, with the patient in a sitting position.
Topography and access to the carotid arteries
The common carotid artery is the main artery located in the neck. She, along with the vagus nerve and the internal jugular vein in the lower half of the neck, is projected into the regio sternocleidomastoideus. Slightly below the level of the upper edge of the thyroid cartilage, the artery emerges from under the anterior edge of the muscle and divides into the internal and external carotid arteries. The bifurcation of the artery is located at the level of the notch of the thyroid cartilage and is projected in the carotid triangle of the neck. Within this triangle, both the common carotid artery and both of its branches are most accessible for exposure. The classical projection line of the common carotid artery is drawn through points, the upper of which is located midway between the angle of the lower jaw and the apex of the mastoid process, the lower one corresponds to the sternoclavicular joint on the left, and is located 0.5 cm outward from the sternoclavicular joint on the right. To verify (identify) the external and internal carotid arteries, the following features are used: the internal carotid artery is located not only posteriorly, but, as a rule, also lateral (outward) from the external carotid; branches depart from the external carotid artery, while the internal carotid artery does not give branches on the neck; temporary clamping of the external carotid artery above the bifurcation leads to the disappearance of pulsation a. temporalis superficialis and a. facialis, which is easily determined by palpation.
It should be remembered that forced ligation of the common or internal carotid artery in case of injury in 30% of cases leads to death due to severe disorders of cerebral circulation. Equally unfavorable is the prognosis for the development of a bifurcation thrombus, which sometimes develops with an incorrect choice of the level of ligation of the external carotid artery. To avoid this complication, the ligature on the external carotid artery must be applied above the origin of its first branch - a. thyreoidea superior.
Topography of the cervical part of the thoracic lymphatic duct
Injuries to the cervical part of the thoracic duct are observed during sympathectomy, strumectomy, removal of supraclavicular lymph nodes, endarterectomy from the common carotid artery. The main clinical manifestation of a violation of the integrity of the thoracic duct is chylorrhea - the outflow of lymph. Measures to eliminate chylorrhea are tamponade of the wound or ligation of the ends of the damaged duct.
In recent years, the operation of imposing a lymphovenous anastomosis between the end of the damaged thoracic duct and the internal jugular or vertebral vein has been used. Access to the thoracic duct and its isolation for repair of damage or performing catheterization and drainage in typical cases is carried out along the medial edge of the sternocleidomastoid muscle. It should be emphasized that the cervical part of the thoracic duct is difficult to access for direct examination.
Tracheostomy is the operation of opening the trachea with the subsequent introduction of a cannula into its lumen in order to provide immediate air access to the lungs in case of obstruction of the overlying sections of the respiratory tract. The first operation was carried out by the Italian Antonio Brassavola (1500–1570). Classic indications for tracheostomy: foreign bodies of the respiratory tract (if it is impossible to remove them with direct laryngoscopy and tracheobronchoscopy); impaired airway patency in wounds and closed injuries of the larynx and trachea; acute stenosis of the larynx in infectious diseases (diphtheria, influenza, whooping cough, measles, typhus or relapsing fever, erysipelas); stenosis of the larynx with specific infectious granulomas (tuberculosis, syphilis, scleroma, etc.); acute stenosis of the larynx in nonspecific inflammatory diseases (abscessing laryngitis, laryngeal tonsillitis, false croup); stenosis of the larynx caused by malignant and benign tumors (rarely); compression of the tracheal rings from the outside by struma, aneurysm, inflammatory infiltrates of the neck; stenoses after chemical burns of the mucous membrane of the trachea with acetic essence, caustic soda, sulfuric or nitric acid vapors, etc.; allergic stenosis (acute allergic edema); the need to connect artificial respiration apparatus, artificial lung ventilation, controlled breathing in case of severe traumatic brain injury; during operations on the heart, lungs and abdominal organs; in case of poisoning with barbiturates; with burn disease and many other less common conditions. Tracheostomy requires both general surgical instruments (scalpels, tweezers, hooks, hemostatic forceps, etc.) and a special set of instruments. The set of the latter usually includes: tracheostomy cannulas (Luer or Koenig), a sharp single-tooth tracheostomy hook of Chessignac, a blunt hook for pushing back the isthmus of the thyroid gland; tracheo dilator for pushing the edges of the tracheal incision before inserting a cannula (Trousseau or Wulfson) into its lumen. Depending on the place of opening of the trachea and in relation to the isthmus of the thyroid gland, there are three types of tracheostomy: upper, middle and lower. With an upper tracheostomy, the second and third tracheal rings are cut above the isthmus of the thyroid gland. The intersection of the first ring, and, moreover, the cricoid cartilage, can lead to stenosis and deformation of the trachea or chondroperichondritis, followed by stenosis of the larynx. With a middle tracheostomy, the isthmus of the thyroid gland is dissected and the third and fourth tracheal rings are opened. With a lower tracheostomy, the fourth and fifth tracheal rings are opened below the isthmus of the thyroid gland. During the operation, the patient can be either in a horizontal position, lying on his back with a roller placed under the shoulder blades, or in a sitting position with his head slightly thrown back. The operator becomes to the right of the patient (with the upper and middle tracheostomy) or to the left (with the lower one). The patient's head is held by an assistant in such a way that the middle of the chin, the middle of the upper notch of the thyroid cartilage and the middle of the jugular notch of the sternum are located on the same line. The incision is made strictly along the midline of the neck. With an upper tracheostomy, the incision is made from the level of the middle of the thyroid cartilage down by 5-6 cm. The “white line” of the neck is cut along the probe and the long muscles located in front of the trachea are pulled apart. Immediately below the thyroid cartilage, the visceral sheet of the 4th fascia is dissected in the transverse direction, fixing the isthmus of the thyroid gland to the trachea. With a lower tracheostomy, an incision of the skin and subcutaneous tissue starts from the upper edge of the jugular notch of the sternum and is carried upwards by 5–6 cm. The 2nd fascia of the neck is dissected, the tissue of the suprasternal interaponeurotic space is bluntly stratified, if necessary, bandaged and crossed here arcus venosus juguli. The 3rd fascia is cut along the probe and the sternohyoid and sternothyroid muscles are moved apart. Below the isthmus, the 4th fascia is incised and the isthmus is displaced upward, exposing the 4th–5th tracheal rings. Before opening the trachea, to suppress the cough reflex, it is recommended to inject 1–1.5 ml of a 2% dicaine solution into its lumen with a syringe. The opening of the trachea can be done either by a longitudinal incision or a transverse one. According to special indications (for example, in patients who are on controlled breathing for a long time), a tracheostomy method is used with cutting out a flap according to Bjork or excision of a section of the wall to form a “window”. During a longitudinal dissection of the trachea, the scalpel is held at an acute angle to the surface of the trachea (not vertically), with the belly up, and 2 rings are crossed after tracheal puncture by moving from the isthmus of the thyroid gland and from the inside outward, as if “ripping” the wall. This technique allows avoiding injury to the posterior wall of the trachea, as well as dissecting the movable mucous membrane along the entire length of the incision. With a longitudinal dissection of the trachea, the integrity of the cartilage is inevitably violated, which in the future can lead to cicatricial deformity and the development of tracheal stenosis. Transverse dissection of the trachea between the rings is less traumatic.
Complications: bleeding from damaged cervical veins, carotid arteries or their branches, veins of the thyroid plexus, innominate artery, as well as when the isthmus of the thyroid gland is injured; incomplete dissection of the mucous membrane, which leads to its exfoliation with cannulas; “falling through” the scalpel and wounding the posterior wall of the trachea or esophagus; recurrent nerve damage. After opening the trachea, respiratory arrest (apnea) is possible due to reflex spasm of the bronchi.
Topographic anatomy and operative surgery of the thyroid gland
Surgeons began to develop operations on the thyroid gland from the end of the last century. Of the foreign surgeons, Kocher (1896) should be noted, who developed in detail the technique of operations on the thyroid gland. In Russia, the first operation was performed by N. I. Pirogov in 1849. The thyroid gland consists of two lateral lobes and an isthmus. The lateral lobes are adjacent to the lateral surfaces of the thyroid and cricoid cartilages and the trachea, reach the lower pole of 5–6 tracheal rings and do not reach the upper edge of the sternum by 2–3 cm. The isthmus lies in front of the trachea, at the level of its 4th rings. The upper edge of the isthmus sometimes comes into contact with the lower edge of the thyroid cartilage. The gland is closely connected with the underlying tissues by loose connective tissue and ligaments, especially with the larynx and the first tracheal rings. Due to this fixation, it follows the movements of the pharynx and trachea during swallowing. Palpation of the gland at the time of swallowing helps to detect even small enlargements and seals, especially in the lower parts of the gland. The posterior medial surfaces of the lateral lobes of the thyroid gland are adjacent to the esophageal-tracheal grooves, in which the recurrent nerves are located. In this zone, exfoliation of a thyroid tumor requires special care, since aphonia may develop if the recurrent nerves are damaged. The neurovascular bundles of the neck (common carotid artery, vagus nerve and internal jugular vein) are adjacent to the outer sections of the lateral lobes of the gland. In this case, the common carotid artery is so closely in contact with the gland that a longitudinal groove is formed on it. The lateral lobes touch the anterolateral wall of the esophagus. The blood supply to the gland is carried out by branches of the external carotid and subclavian arteries. Paired superior thyroid arteries, arising from the external carotid arteries, approach from the posterior surface to the upper poles of the lateral lobes and branch mainly in the anterior sections of the gland. Paired inferior thyroid arteries, arising from the subclavian arteries (truncus thyreocervicalis), approach the lower poles of the lateral lobes and supply mainly the posterior sections of the gland with branches. In 10–12% of cases, the inferior thyroid artery, which directly departs from the aorta and enters the lower isthmus of the gland, participates in the blood supply.
One of the most common thyroid surgeries is a strumectomy. The technique of the most frequently used operation was developed by O. V. Nikolaev (1964). It is called subtotal subcapsular resection of the thyroid gland. Surgical access is carried out by a horizontal arc-shaped incision 1-2 cm above the jugular notch of the sternum 8-12 cm long along one of the transverse skin folds ("collar" incision). When dissecting soft tissues, a thorough ligation of the vessels is performed. The resulting flaps, including the skin, subcutaneous tissue and superficial fascia, are peeled off in a blunt way and bred up and down. The sternohyoid muscles are transversely crossed. After the introduction of novocaine under the sternothyroid muscles and into the fascial sheath of the thyroid gland, the muscles are moved apart from the midline, and the parietal sheet of the 4th fascia of the neck is dissected. By displacing the edges of the dissected fascia in a blunt way, they provide an approach to the thyroid gland and begin to perform an operative technique. The allocation of the organ begins with the "dislocation" of the gland, usually from the right lobe, depending on the situation from the upper or lower poles. After the release of the right lobe, the isthmus of the thyroid gland is crossed along the probe (or under the control of a finger). As the isthmus is dissected, hemostatic clamps are applied sequentially. Less often, the isthmus is crossed between the clamps, followed by stitching its tissue and tightening the ligatures. This is followed by a "navicular" excision of the tissue of the right lobe of the gland, which is performed under the control of the finger. This moment requires a thorough stop of bleeding and the imposition of a large number of clamps. By controlling the movement of the scalpel with a finger under the gland, a narrow plate of gland tissue is left in the area that is considered a “dangerous” zone, since the recurrent nerve and parathyroid glands are adjacent to it behind. The remaining part of the gland (a plate of tissue of the right and left lobes a few millimeters thick) should be sufficient to prevent hypothyroidism. The medial and lateral edges of the left parenchyma of the gland are sutured to each other in the form of two valves. The bed of the removed gland and the remaining stump is covered by the sternothyroid muscles. Then the sternohyoid muscles crossed during access are sutured and sutures are applied to the skin.
From the book How to stay healthy author Gennady Petrovich MalakhovHow to clean vessels? At one time I sorted out various cleanings for myself - there are a huge number of them and ... you can really get confused, clean, clean and really get nothing. Therefore, you need to "look at the root" - to understand the main thing and move from it to
From the book Cleansing for Beauty and Youth author Inna A. Kriksunova From the book Operative Surgery author I. B. GetmanWe clean the vessels Clean vessels - healthy cells - healthy
From the book Histology author V. Yu. Barsukov24. Triangles and fasciae of the neck With a horizontal plane drawn at the level of the body of the hyoid bone, the anterior neck is divided into suprahyoid and infrahyoid regions. The muscles located in the suprahyoid region form the bottom of the oral cavity, in this area
From the book Point of Pain. Unique massage for pain trigger points author Anatoly Boleslavovich Sitel28. Lymphatic vessels Lymphatic vessels drain lymph into the venous bed. Lymphatic vessels include lymphatic capillaries, intra- and extraorganic lymphatic vessels that drain lymph from organs, and lymphatic trunks of the body, to which
From the book Homeopathic Handbook author Sergei Alexandrovich NikitinPain in the neck, shoulder girdle, supraclavicular region and arm The most pronounced pain in the supraclavicular region occurs with spasm of the anterior scalene muscle. The anterior scalene muscle originates from the transverse processes of the III and VI cervical vertebrae and is attached to
From the book Dictionary of Medical Terms author author unknownFascia Stone-hard tumors in the fascia - Calcarea
From the book Get rid of the pain. Pain in the region of the heart author Anatoly SitelFascia (fasciae) 847. F. abdominis interna profunda, deep internal fascia of the abdomen - see F. transversalis.848. F. abdominis superficialis, superficial fascia of the abdomen - located between the subcutaneous fat layer and its own fascia, covering the sheaths of the rectus abdominis muscles and the external oblique abdominal muscles;
From the book Knee Pain. How to restore joint mobility author Irina Alexandrovna ZaitsevaPain in the region of the heart and digestive organs Pain in the region of the heart may be associated with diseases of the internal organs located in close proximity to the heart. The internal organs from the spine through the nerves constantly receive electrical impulses,
From the book Iplicator Kuznetsov. Relief from back and neck pain author Dmitry KovalBlood vessels Blood vessels are located on the back of the knee joint near the popliteal nerve. The popliteal vein and artery provide blood circulation in the lower leg and foot. The popliteal artery carries blood to the foot, and the vein back to the
1. Inner triangle(limited by the edge of the lower jaw, sternocleidomastoid muscle and midline of the neck):
Submandibular triangle(limited to the mandibular margin and both bellies of the digastric muscle). Contents: submandibular salivary gland and lymph nodes of the same name, facial artery, lingual and hypoglossal nerves.
sleepy triangle(limited to the posterior belly of the digastric muscle, the anterior edge of the sternocleidomastoid and the upper belly of the scapular-hyoid muscles). Contents: the main neurovascular bundle of the neck, including the common carotid artery, internal jugular vein, vagus nerve.
Scapulotracheal triangle(limited to the upper abdomen by the scapular-hyoid and sternocleidomastoid muscles and the midline of the neck). Contents: common carotid, vertebral arteries and veins, inferior thyroid artery and vein, vagus nerve and sympathetic cardiac nerves, inferior laryngeal nerve, cervical loop.
2. Outer triangle(limited to clavicle, sternocleidomastoid and trapezius muscles):
Scapular-trapezoid triangle(limited to the sternocleidomastoid, lateral edge of the trapezius, lower abdomen of the scapular-hyoid muscles). Contents: cervical plexus and its dermal branches.
Scapular-clavicular triangle(limited to the sternocleidomastoid, lower abdomen of the scapular-hyoid muscles and the clavicle). Contents: subclavian artery and vein, trunks of the brachial plexus, thoracic lymphatic duct.
Fascia of the neck and their applied significance Functions of the fascia of the neck:
Protective;
Fixation;
Promote muscle biomechanics;
Limit cellular spaces;
regulation of the inflow and outflow of blood from the brain due to their fusion with the outer shell of the veins (for the same reason, air embolism may develop due to non-falling of the veins during injuries, the proximity of the right atrium and the suction action of the chest).
Topography of the main neurovascular bundle of the neck. Projection line for exposing it in the upper and lower sections.
The projection of the main neurovascular bundle of the neck is determined by the line connecting the middle of the sternoclavicular joint.
It must be remembered that this projection line is correct only with the head turned to one side.
The composition of the main neurovascular bundle includes the following five formations:
1. common carotid artery.
2. internal jugular vein.
3. vagus nerve.
4. descending branch of the hypoglossal nerve.
5. jugular lymphatic duct.
The syntopy, or relationship, of the elements of the main neurovascular bundle in the neck is as follows.
The most medial is the trunk of the common carotid artery. From the inside, the trachea is adjacent to it and behind the esophagus. Outside of the artery lies the internal jugular vein, which has a much larger cross section. Between these vessels at the back in the groove between them lies the vagus nerve. The descending branch of the hypoglossal nerve at the top lies on the anterior surface, and below on the anterior surface of the common carotid artery, along which it descends until it pierces the anterior muscles of the neck, which this branch innervates.
The fifth formation of the neurovascular bundle - the lymphatic jugular duct - is located on the outer or anterior surface of the internal jugular vein in the thickness of the tissue covering it.
Anatomical and surgical rationale for ligation of the external carotid artery, common carotid artery.
However, the intervention on the carotid artery is associated not so much with glomectomy, but with its ligation. Indications for exposure and ligation of the common carotid artery are:
a) damage to the walls of the artery;
b) aneurysms;
c) previous dressing in order to prevent severe bleeding during surgical interventions on the upper and lower jaws.
Surgical approaches in the neck area
Operative access to the organs of the neck must simultaneously meet cosmetic requirements and provide sufficient access to perform the necessary intervention.
There are four groups of surgical approaches on the neck.
Vertical (upper and lower) accesses most often carried out along the midline of the neck. These accesses are widely used for tracheostomy, but at the same time leave a noticeable scar.
Oblique accesses carried out along the anterior or posterior edge of the sternocleidomastoid muscle; they are used to expose the neurovascular bundle of the medial triangle of the neck and the cervical esophagus. The advantage of oblique incisions is that they are safe and provide sufficient access to the depth of the neck.
Transverse approaches used to approach the thyroid gland (Kocher access), pharynx, vertebral, subclavian and inferior thyroid arteries, as well as to remove cancer metastases. The advantage of most transverse approaches is that they meet the requirements of cosmetic effect, since they are carried out according to the location of natural skin folds. The disadvantages of transverse approaches include, firstly, the fact that the subcutaneous muscle of the neck is cut transversely (which sometimes leads to the formation of keloid scars, and secondly, certain difficulties arise when working in the deep sections of the neck. In addition, transverse accesses do not coincide with the direction of most of the cervical muscles, vessels and nerves.
Combined accesses.They are used for wide opening of cellular spaces, removal of tumors and metastatic nodes. Most often combine transverse and oblique accesses. Combined incisions are traumatic and leave noticeable scars after them.
Surgical anatomy and topography of the larynx. Vocal cords. Blood supply and innervation of the larynx. Conicotomy.
Larynx
The skeleton of the larynx is formed by nine cartilages (three paired and three unpaired). The basis of the skeleton 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, which is connected to the hyoid bone by a membrane - membranahyothyreoidea. From the cricoid cartilage to the thyroid cartilage go mm. cricothyreoidei and lig. cricothyreoidum.
Departments:
1) upper (vestibule) - from the epiglottis to the false vocal cords;
2) average ( interligamentous space) - the location of the false and true vocal cords;
3) lower (subglottic space).
Skeletotonia The larynx is located within the range from the lower edge of the IV cervical vertebra to the lower edge of the VI cervical vertebra.
Syntopy. It is covered in front by the preglottal muscles, on the sides are the lateral lobes of the thyroid gland, behind
- pharynx; reaches the root of the tongue in the upper sections, passes into the trachea below.
Blood supply: branches of the superior and inferior thyroid arteries.
Innervation: superior and inferior laryngeal nerves; branched sympathetic nerve.
Conicotomy.
Conicotomy- opening of the larynx by dissection of the thyroid cricoid ligament. The operation is performed in emergency cases, namely, with acute respiratory failure that develops with a trauma to the larynx, obturation of its lumen with a foreign body, i.e., in cases where there is no time for a tracheostomy.
Technique. A one-time vertical incision along the midline of the neck below the thyroid cartilage is used to dissect the skin and thyroid cricoid ligament. A clamp is inserted into the incision and the branches are moved apart, which immediately ensures the flow of air into the respiratory tract. After the disappearance of asphyxia, the conicotomy is replaced by a tracheostomy, since a long stay of the cannula near the cricoid cartilage is usually complicated by chondroperichondritis, followed by stenosis of the larynx and trauma to the vocal apparatus.
As a rule, after restoration of external respiration with the help of Conictomy and in the absence of general (severe condition of the patient) or local (large tumor in the upper trachea) contraindications, a tracheotomy is performed and the tracheotomy tube is rearranged into the tracheostomy. The need for this is due to the rapid involvement in the inflammatory process of the surrounding soft tissues and cartilage of the larynx with a long course, subsequent scarring and deformation of the walls of the larynx.
The upper border of the neck is drawn (right and left) from the chin along the base and posterior edge of the lower jaw branch to the temporomandibular joint, continues posteriorly through the top of the mastoid process of the temporal bone along the upper nuchal line to the outer protrusion of the occipital bone.
The lower border of the neck runs on each side from the jugular notch of the sternum along the upper edge of the clavicle to the apex of the acromion and then to the spinous process of the VII cervical vertebra.
Taking into account the relief of the skin on the neck, due to the position of the underlying muscles, internal organs, the following areas of the neck are distinguished in the anterior sections: anterior, sternocleidomastoid (right and left) and lateral (right and left), as well as back.
front of the neck, or anterior triangle of the neck(regio cervicalis anterior, s.trigonum cervicale anterius), limited on the sides by sternocleidomastoid muscles. At the top, the base of the triangle is formed by the lower jaw, and its apex reaches the jugular notch of the manubrium of the sternum.
In the anterior region of the neck, in turn, are distinguished on each side medial triangle of the neck, bounded in front by the median line, above - by the lower jaw and behind - by the anterior edge of the sternocleidomastoid muscle. A conditional horizontal plane drawn through the body and large horns of the hyoid bone divides the median region of the neck (anterior triangle) into two regions: the upper suprahyoid(regio suprahyoidea) and lower sublingual(regio unfrahyoidea). In the sublingual region of the neck, two triangles are distinguished on each side: sleepy and muscular (scapular-tracheal).
Sleep triangle (trigonum caroticum) limited from above by the posterior belly of the digastric muscle, behind - by the anterior edge of the sternocleidomastoid muscle, in front and below - by the upper belly of the scapular-hyoid muscle. Within this triangle above the superficial plate of the cervical fascia are the cervical branch of the facial nerve, the superior branch of the transverse nerve of the neck, and the anterior jugular vein. Deeper, under the superficial plate of the cervical fascia, are the common carotid artery, the internal jugular vein, and behind them the vagus nerve, enclosed in a common sheath of the neurovascular bundle. Here lie the deep lateral cervical lymph nodes. Within the carotid triangle at the level of the hyoid bone, the common carotid artery divides into the internal and external carotid arteries. Its branches depart from the latter: the superior thyroid, lingual, facial, occipital, posterior auricular, ascending pharyngeal arteries and sternocleidomastoid branches, heading to the corresponding organs. Here, anterior to the sheath of the neurovascular bundle, is the upper root of the hypoglossal nerve, deeper and lower - the laryngeal nerve (a branch of the vagus nerve), and even deeper on the prevertebral plate of the cervical fascia - the sympathetic trunk.
Muscular (scapular-tracheal) triangle(trigonum musculare, s. omotracheale) is bounded behind and below by the anterior edge of the sternocleidomastoid muscle, above and laterally by the upper abdomen of the scapular-hyoid muscle and medially by the anterior median line. Within this triangle, immediately above the jugular notch of the manubrium of the sternum, the trachea is covered only by the skin and the fused superficial and pretracheal plates of the cervical fascia. Approximately 1 cm away from the midline is the anterior jugular vein, which extends into the suprasternal interfascial cellular space.
In the suprahyoid region, three triangles are distinguished: submental (unpaired) and paired - submandibular and lingual.
Submental triangle (trigonum submentale) limited on the sides by the anterior bellies of the digastric muscles, and the hyoid bone serves as its base. The apex of the triangle is turned upwards, towards the mental spine. The bottom of the triangle is the right and left jaw-hyoid muscles that are connected by a seam. In the region of this triangle are the submental lymph nodes.
Submandibular triangle (trigonum submandibulare) formed at the top by the body of the lower jaw, at the bottom - by the anterior and posterior bellies of the digastric muscle. The salivary gland of the same name (submandibular) is located here. The cervical branch of the facial nerve and the branching of the transverse nerve of the neck penetrate into this triangle. Here, the facial artery and vein are superficially located, and behind the submandibular gland is the submandibular vein. Within the submandibular triangle under the lower jaw are the lymph nodes of the same name.
Lingual triangle (Pirogov's triangle) small, but very important for surgery, is located within the submandibular triangle. Within the lingual triangle is the lingual artery, which can be accessed at this point in the neck. Anteriorly, the lingual triangle is bounded by the posterior margin of the maxillohyoid muscle, posteriorly and inferiorly by the posterior belly of the digastric muscle, and superiorly by the hyoid nerve.
In the lateral region of the neck, the scapular-clavicular and scapular-trapezoid triangles are distinguished.
Scapular-clavicular triangle (trigonum omoclaviculare) located above the middle third of the clavicle. From below, it is limited by the clavicle, from above - by the lower abdomen of the scapular-hyoid muscle, in front - by the posterior edge of the sternocleidomastoid muscle. In the area of this triangle, the final (third) part of the subclavian artery, the subclavian part of the brachial plexus, between the trunks of which the transverse artery of the neck passes, and above the plexus, the suprascapular and superficial cervical arteries. Anterior to the subclavian artery, in front of the anterior scalene muscle (in the prescalene gap), lies the subclavian vein, firmly fused with the fascia of the subclavian muscle and the plates of the cervical fascia.
Scapular-trapezoid triangle (trigonum omotrapezoideum) formed by the anterior edge of the trapezius muscle, the lower belly of the scapular-hyoid muscle and the posterior edge of the sternocleidomastoid muscle. The accessory nerve passes here, the cervical and brachial plexuses are formed between the scalene muscles, the small occipital, large occipital and other nerves depart from the cervical plexus.
