Neck (2)

Common Carotid artery :-

• lies within the medial part of the carotid

sheath, with the internal jugular vein lateral to
it and the vagus nerve deeply placed between
the two vessels .
• The sympathetic trunk is behind the artery and
outside the sheath .
• Common carotid bifurcates at the upper border
of thyroid cartilage which is actually at C4
vertebra into internal & external carotid arteries.
• How to differentiate between external & internal
carotid artery ?
• Answer : by the following differences:-

1. Relation :-
• Initially external carotid is medially to the
internal one. But this relation will change  
later on when they are going to the head ; the
external carotid artery will become anterior
and the internal will become posterior because
the external carotid artery supply the outer
structures like : pharynx,nose, oral cavity and it's
doesn't supply the brain , and the internal carotid
 artery supply the brain .

2. Dilation :-
• Initially the internal carotid artery have dilations
caused by carotid receptors (baro - and
chemo - receptors) which is  are innervated by
glossopharyngeal and vagus nerves & important
for regulation of blood pressure and respiration

3. Branches :-
• external carotid artery gives branches in the
neck. but the internal carotid artery dose not give
branches till it reache the skull.
• The styloid process and muscles attached ,
Stylohyoid ligaments , deep part of the parotid
gland to it is the separating structures between
the internal and external carotid arteries ; the
muscles attached to styloid process are :
1. Styloglossus : from styloid process to the tongue.

2. Stylopharyngeus : from styloid process

to the pharynx

3. Stylohyoid ligament & glossopharyngeal nerve

★ ( what are the structure that separate the internal

and the external carotid arteries ? Ans 6 structures )

•--------------------------------------------------•

External Carotid Artery :-

Has Anterior branches , posterior branches , medial

branches and two terminal division .

# Anterior branches :-

1. Superior thyroid artery :-

• which give branch inter the larynx called superior
laryngeal artery  which pirece the thyrohyoid
membrane between the thyorid cartilage and the
hyoid bone to enter the larynx and it accompanied
by the internal laryngeal nerve which is branch
of superior laryngeal nerve which is branch
of the vagus nerve.
• So this thyrohyoid membrane ( If you asked in
msqs) is pirece by three structures: The internal
laryngeal nerve , Superior laryngeal artery & Vein.
• Not that there is also external laryngeal nerve
which is branch of the superior laryngeal nerve.
This external laryngeal nerve flows the superior
thyroid artery for a few then it cross to enter the
larynx and it supply a muscle called cricothyroid
between the cricoid and thyroid cartilages and
this muscle is responsible for the power of the
voice  (high pitch voice) and not the production
 of voice. So cutting of this nerve e.g on
thyroidectomy cause very low voice .
• Injury of recurrent laryngeal nerve is more
dangerous than injury of superior laryngeal nerve
because it supply the muscles that responsible
for production of the voice and also breathing .

2. Lingual artery :-
• form a loop crossed by hypoglossal nerve , then
it ascend to the tongun

3. Facial artery :-
• it go deep to posterior belly of digastric then
deep to the mylohyoid so it also deep for
submandibular gland
• it gives :-
1. tonsilar branch that supply the tonsils
2. Ascending palatine artery which supply
the palate 
3. Anastamotic branches with lingual artery
so ligation of lingual artery dose not  cause
ischemia of the tongue
4. Submental branch

•  Then it pass anterior to  a muscle called

the masseter. Become a superficial and go
 to supply the face

# Medial Branche :-
• Ascending pharyngeal artery

# Posterior branches include:-

1. Occipital artery :
• which supply the sternocledomastoid and have
upper and lower branches.
2. Posterior auricular artery :-
• Passes behind ( i.e the ear ) the external
acoustic meatus .

• Then the external carotid artery within the parotid

gland devided into two :-
1. Superficial temporal Artery : Anterior to the ear 
and all of you can feel it's pulse & sometimes it
undergo arthritis or vasculaitis and the patients
come with temporal headache mainly in old
people and usually we diagnose it by biopsy .

2. Maxillary artery : which go deep to enter

the infratemporal fossa supplying the mouth
and the nose
• So the branches if the External carotid
artery are :-

1. Superior thyroid artery

2. Lingual artery
3. Facial artery
4. Occipital artery
5. Posterior auricular artery
6. Ascending phyrngeal artery
7. Superficial temporal artery
8. Maxillary artery
•--------------------------------------------------•

» Internal jugular vein :-

• Descend behind SCM and take acover from it.

• So you can't reach it because it protected by the
muscle and if you want to reach it you have one
chance in the triangular interval between the two
heads of origin and you can do catheterization in
this interval 30 degree to the body of the sternum
in direction of the heart .
• Therefore internal jugular vein is not content
of carotid triangle because it lie behind the
boundary ( i.e SCM ) .
• The deep cervical fascia rapp around the internal
jugular vein and around common carotid and
around the internal carotid artery
• The vagus nerve cources in the carotid sheath
between the internal jugular vein and the
common carotid artery then between the
internual jugular vein and the internal carotid
artery  ( so the vagus nerve has no relation to the
external carotid artery )

• Contents of the carotid sheath:-

1. Common carotid artery

2. Internal carotid artery
3. Internal jugular vein
4. Vagus nerve
5. Deep cervical Lymph nodes
6. Annsa cervicalis.

Note :-
• the contents of carotid triangle dose not include
the internal jugular vein and the contents of
carotid sheath dose not include the external
carotid artery  .
•--------------------------------------------------•

External jugular vein :-

• Cross the sternocledomastoi ( seen in
angry person ) .
•--------------------------------------------------•

 » Posterior triangle of the neck :-

• # Boundaries :-
• Sternocledomastoid ,Medial third of the
clavicle & Trapizeus.

• # Roof :-
• the investing layer of the deep cervical fascia.

• # Floor :-
• prevertebral fascia .

• Deep to this floor there is prevertebral muscles ;

in the centre there is levator scapulae , below it
there is scalnes medius ( which is origin come
from cervical vertebrae and inserted into first
rib ) , above  levator scapulae there is splenius
capities (capities mean. attached to the skull ) and
it's actually extension of the fascia of the back.
• The above three muscles are the main muscles of
the floor of posterior triangle .
• Sometime depending on the muscles origin and
insertion scalneus anterior , first digitation of
serratus anterior and semispinalis capitis may be
contribute in the formation of the floor .
• The cervical and brachial plexuses are found deep
to the prevertebral facia , but we still consider
them as content of the triangle .

• The muscles of the floor of posterior triangle

with lower trunks of brachial plexus and cervical
plexus  sometimes considerd as content ).
• # The contents of posterior triangle :-
1. ★Lymph node .
2. Trunks of the Brachial plexus .
3. Brnaches of Cervical plexus .
4. Splenius capitis , Levator scapulae and
scalenus medius .
5. ★ Accessory nerve :-
• Cranial nerve number 11 coming supply the
sternocledomastoid then it inter in the upper part
of the triangle and. go to supply the trapizus.
• it's most important content of posterior triangle
because it can easily be injured during surgery
• If the injury in the posterior triangle trapizus will
be affected and sternocledomastoid will not be
affected unless injury is in the skull .

• If sternocledomastoid is affected we know

that by asking the patient to turn his head
to the opposite site and we see that there
 is no contraction .
• When the trapizus affected shoulder
drop will occur.

• Sometime sternocledomastoid is overcontracted

in condition called torticollis. and it may be
congenital and the child born and he can't turn his
face to the opposite site .
• We can treat this condition by by cutting
the muscle fibers .

• The posterior triangle devided by the

inferior belly of omohyoid into upper
occipital and lower supraclavicular part.
•--------------------------------------------------•

Cervical Plexus :-

• Found in the occipital part of the triangle  .

• Formed of anterior rami of C1 till C4 .
• Has motor ,sensory and proprioceptive branches .

# Motor branches :-

• 1. Phrenic nerve :-
• Come from C3 , C4 , C5 but mainly C4 .
• descend anterior to scalneus anterior crossing it
from lateral to medial  and posterior to it's fascia
then it enter the thorax between the subclavian
vein & subclavian artery .
• The phrenic nerve is unlikely to be injured
because it plastered to the muscle fascia

• 2. Ansa cervicalis :-
• from C1 that form the superior root and
C2 , C3 that form the inferior root , the two
roots meet anterior to internal jugular vein
over the carotid sheath and the nerve firmly
attached to the sheath so it can be considerd
as content of sheath.

• 3. Motor branches from cervical vertebra randomly

to the prevertebral muscles

• 4. Motor Nerve from C1 that run with hypoglossal

nerve to genohyoid and thyrohyoid muscles .

# Proprioceptive branches :-
• proprioception is deep sensation of the muscle
and any muscle should have proprioceptive
branches to stretch .
• 1. C2 & C3 give proprioceptive branches to
 sternocledomastoid

• 2. C3 & C4 give proprioceptive branches

to trapizus

• 3. All cervical vertebrae give proprioceptive

branches to prevertebral muscles 

# Sensory branches :-
• 1. sensory branch from C1 run with hypoglossal
nerve to enter through the formaen magnum
supplying the meninges .

• ★ so the fiber from C1 run with the hypoglossal

nerve to :-
1. Motor Supply to geniohyoid muscle &
thyro-hyoid muscle .
2. Sensory Supply to the meninges .
3. From the upper root of Ansacervicalis nerve .

• 2. Sensory Branches from C2 & C3 that directly

supply the meninges ( passe through the
foramen magnum ) .
• in meningitis the patients come with headache
and neck stiffness .
• this stiffness can be explained by fact that
cervical plexus supply the prevertebral muscles
( motor and proprioceptive ) and meninges
at the same time .

• 3. There are also four cutaneous sensory  nerves

that supplying the neck include :-

• 1. lesser occipital nerve :-

• Arise from of anterior rami C2 parallel to stern-

ocledomastoid and run behind the ear to give sen-
sory innervation to the occipital area and here is
supported by great and third occiptal which arises
from Posterior rami of C2 & C3 respectively .
• hooks around the accessory nerve .

• 2. Great auricular nerve :-

• Arise from C2 and C3 give & cross the

sternocledomastoid to reach the parotid fascia
supply it and supply the skin of the angle of the
mandible and upper part of the neck & lower part
of the auricle below the orifice and and skin over
the mastoid region .
• People who have inflammation of parotid gland
 called mumps  the referred pain Of inflammation
mediated  by this nerve which supply the
capsule and the fascia

• 3. Transverse cervical nerve :-

• Arise from C2 and C3 again cross the

sternocledomastoid and divides into ascending
and descending branches that supplying the
anterior skin of the neck from hyoid or the
mandible till the suprasternal notch .
• The ascending branch communicates with the
cervical branch of the facial nerve .

4. Supraclavicular nerves :-

• Arise from C3 and C4 , approximately 3 in number

supply the skin over the clavicle, sternal angle,
nipple, scapular spine .
• The medial group supply the skin as far down
as the sternal angle.
• The intermediate group proper pass anterior
to the clavicle and supply skin as far down
as the second rib.
• The lateral group cross the acromion to supply
skin halfway down the deltoid muscle, and pass
posteriorly to supply skin as far down as the
 spine of the scapula .

• ★ Note :-
• SCM is crossed by 3 structures , one vein
and 2 nerves .

» Supraclavicular part of the posterior triangle :-

• The most important landmark here is the

scalneus anterior muscle which arises from
transverse process of C3 C4 C5 and C6 and it's
fibers will converge in triangular shape and go
to be inserted in scalne tubercle of the first
rib crossed from behind by subclavian artery
which has three parts :-
• First part medial to the muscle
• Second part behind the muscle
• Third part & With the trunks of brachial plexus
lateral to the muscle .
• Subclavian vein , the phrenic nerve , Transverse
cervical and Suprascapular arteries and carotid
sheath anterior to the muscle .

#  Branches of first part of subclavian artery:-

• 1. Vertebral artery that enter at the apex of

 triangle fromed by scalneus anterior and longus
colli ( that cover the cervical vertebrae ) this
artery  enter the formaen transvarsium of C6 .
• Formaen transvarsium of C7 transmit the
vertebral vein and sympathetic fibers .

• 2. Internal thoracic or internal mammary artery .

• 3. Thyrocervical trunk :-
• Lateral to vertebral artery  gives :-
1. Inferior thyroid artery
2. Ascending cervical artery  ( anterior to the
scalenus anterior )
3. Transverse cervical artery ( lateral to
scalenus anterior ) .
4. Suprascapular artery ( lateral to scalenus
anterior ) .

# Branches of the Second part of

subclavian artery :-

• costocervical trunk which give two branches:-

1. Deep cervical artery
2. Superior intercostal artery ( Supreme intercostal
artety ) supply first posterior intercostal space.
 # branches of the Third part of subclavian :-
• usually have no branches but sometimes it
give dorsal scapular artery which participate in
scapular anastomosis .

Last modified: Sep 14, 2018