Anterior triangle of the neck

- lecture notes -
Boundaries
1) anterior boundary is the median sagittal section
2) posterior boundary is the anterior edge of sternocleidomastoid m.
3) superior boundary is the inferior border of the mandible, and posterior to the mandible it is a line
drawn from the angle of the mandible to the mastoid process
4) roof is the external cervical fascia
5) floor is alternately described as the cervical viscera (e.g., the larynx, pharynx, and thyroid) as in
Liebgott, or as the vertebral column with overlaying anterior prevertebral muscles (with
associated fascia) as in Essentials of Gross Anatomy
Lesser triangles
- created by the omohyoid and digastric mm.
- submandibular (digastric) triangle
- bounded by the posterior belly of the digastric m. plus the intermediate tendon, the anterior
belly of the digastric m., and the inferior border of the mandible
- mylohyoid m. anteriorly and hyoglossus m. posteriorly form the floor
- submental triangle
- bounded by the anterior belly of the digastric mm. and the hyoid bone.
- mylohyoid mm. form the floor
- muscular triangle
- bounded by the hyoid bone, the superior belly of the omohyoid m., the inferior third of the
sternocleidomastoid m., and the median sagittal plane
- carotid triangle
- bounded by the posterior belly of the digastric m., the superior belly of the omohyoid m.,
and the anterior margin of the sternocleidomastoid m.
Structural elements
- bones
- hyoid
- at the level of the C3/C4 intervertebral disk
- body is connected to a greater horn (cornu) on each side by cartilages that fuse
during middle age
- a lesser horn (cornu) is found at each junction of the body and a greater horn
projecting superiorly and posteriorly
- styloid process of the temporal bone
- usually 2-3 cm in length projecting from the base of the skull, just lateral to the
jugular foramen, to the midpoint of the posterior edge of the mandibular ramus
- periosteum is continuous from the styloid process to the lesser horn of the hyoid,
thus forming the stylohyoid ligament between the two bones
- cartilages
- thyroid cartilage
- composed of paired flattened laminae that partially fuse in the midline
- laminae of males are facing slightly more laterally than females, which face slightly
more anteriorly. This sexually dimorphic difference creates a more
distinguishable laryngeal prominence (in common speech this is referred to as the
“Adam’s apple”) in males relative to females.
- a superior horn (cornu) at the posterosuperior edge of each laminae approaches the
tip of the greater horn of the hyoid bone
- an inferior horn (cornu) at the posteroinferior edge of each laminae runs inferiorly
to form a synovial joint with the cricoid cartilage
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 Anterior triangle of the neck
- lecture notes -
- the oblique line runs inferiorly and medially along each lamina and is the site of
muscle attachments
- cricoid cartilage
- shaped as a signet ring, with the broad portion (lamina) facing posteriorly and the
arch running laterally and anteriorly
- lower border is joined by connective tissue to the1st tracheal ring
- where the lamina joins the arches, externally are facets for the inferior horns of the
thyroid cartilage, and superiorly are facets for the arytenoids cartilages
Fascial planes
- external cervical fascia
- investing fascia that runs between the sternocleidomastoid muscles
- middle cervical fascia
- investing fascia around sternohyoids and omohyoids that is continuous between the
muscles
- the portion that invests the intermediate tendon of the omohyoid muscle acts as a pulley by
affixing the tendon closer to the posterior aspect of the clavicle at the level of C7
Cervical cavity
- described as the area between the middle cervical fascia and the vertebral column with its
associated muscles positioned anteriorly to the vertebrae.
- when this description is used, the cavity would contain three regions
- left and right regions for the carotid sheath and its contents
- a central region for viscera (e.g., pharynx, esophagus, larynx, trachea, thyroid glands, and
parathyroid glands)
Viscera
- Esophagus
- posterior and offset to the left of the trachea
- begins at the inferior margin of the cricoid cartilage, travels through the thorax, and
continues until reaching the cardiac orifice of the stomach in the abdomen
- Trachea
- midline structure extending from the cricoid cartilage to the tracheal bifurcation in the
mediastinum
- composed of C-shaped cartilages (tracheal rings) that are open posteriorly
- Thyroid gland
- H-shaped structure resting anterior and lateral to the trachea
- composed of paired lobes with a intervening isthmus (anterior to tracheal rings 2-4)
- inferior poles extend to tracheal rings 5-6
- has a fibrous outer capsule that is fused to the pretracheal fascia (which also attaches to the
laryngeal cartilages)
- Parathyroid gland
- paired structures (superior and inferior) located on the posterior aspects of each lobe of the
thyroid gland
- the superior pair is located near the beginning of the esophagus (the inferior margin of the
cricoid cartilage
- the inferior pair is variable in position, but will always be inferior to the superior pair
- Submandibular (salivary) gland
- rests on the superficial surfaces of the hyoglossus and mylohyoid
- a portion runs deep to the mandible up to where the mylohyoid originates from the
mylohyoid line
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 Anterior triangle of the neck
- lecture notes -
- a duct empties from the posterior portion of the gland and runs deep to mylohyoid
- Parotid (salivary) gland
- occupies the retromandibular region of the neck and extends downward onto the superficial
surface of the posterior belly of the digastric
Muscles
- suprahyoid muscles
- digastric
- embryologically composed of facial (posterior belly) and trigeminal (anterior belly)
somitomeres as their innervation suggests
- nerve to mylohyoid (V3) innervates anterior belly
- origin: digastric groove - just medial to mastoid process
- insertion: digastric fossa - posterior edge of inferior margin of mandible near
midline
- some fibers of anterior belly originate off of the hyoid
- an intermediate tendon (insertion of posterior belly and origin of anterior belly)
interposes between the two bellies of the digastric muscle
- intermediate tendon bound to the junction of the greater horn and body of the hyoid
via a fascial sling
- bellies function separately due to attachment of fascial sling to intermediate tendon
and the fibers of the anterior belly originating off of the hyoid (both help open
the mouth; only the anterior belly helps to close the mouth)
- stylohyoid
- innervated by facial nerve (VII) like the posterior belly of the digastric
- origin: posterolateral portion of the styloid process
- insertion: greater horn of the hyoid
- muscle belly splits at its insertion to envelope the intermediate tendon of the
underlying digastric
- mylohyoid
- innervated by the nerve to the mylohyoid (V3) as is the anterior belly of the
digastric
- origin: mylohyoid line/ridge on the body of the mandible
- insertion: a midline raphe extending from the inferior margin of the mandible to the
hyoid
- contracts to push up the tongue
- active during swallowing
- infrahyoid muscles
- formed by the “rectus cervicis” (i.e., upper three cervical dermomyotomes)
- depress hyolaryngeal structures, which is important during swallowing and vocalization
- enables movements of hyoid to be transmitted to thyroid cartilage (thyrohyoid only)
- innervated by branches from C1-C3 ventral rami
- omohyoid
- composed of superior and inferior bellies with an intervening intermediate tendon
- origin (inferior belly): superior margin of the scapula just medial to suprascapular
notch
- insertion (superior belly): body of the hyoid, lateral to sternohyoid insertion
- note that inferior belly inserts into intermediate tendon and superior belly originates
from the intermediate tendon
- sternohyoid
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 Anterior triangle of the neck
- lecture notes -
- origin: posterior aspects of the manubrium and medial clavicle
- insertion: body of the hyoid, medial to omohyoid (superior belly) insertion
- sternothyroid
- origin: posterior aspects of manubrium and 1st costal cartilage
- insertion: oblique line of thyroid cartilage
- left and right are adjoining at their origins, but diverge on the way to their
insertions
- thyrohyoid
- origin: oblique line of thyroid cartilage
- insertion: inferior margin of hyoid body and greater horn
Vasculature
- arteries
- common carotid
- arise from the brachiocephalic artery or the aortic arch
- travels deep to the medial end of the sternoclavicular joint in passing through the
root of the neck
- travels posterior to the inferior pole of the thyroid, and is gradually displaced
laterally by the remainder of more superior parts of the lobe
- positioned anteriorly to the anterior tubercles of C6
- bifurcates at C4 posterior to the superior horns of the thyroid cartilage
- carotid body
- small cluster of cells in the nook between the origins of external and
internal carotid arteries
- nerve endings [supplied by glossopharyngeal nerve (IX)] provide a means
of monitoring CO2 and O2 content in blood
- carotid sinus
- dilated portion of the common carotid where it bifurcates into the external
and internal carotid arteries
- nerve endings [supplied by glossopharyngeal nerve (IX)] provide a means
of monitoring of blood pressure
- external carotid
- arises from the anterior surface of the common carotid at its bifurcation
- passes deep to the posterior belly of the digastric before the internal carotid artery
does
- after passing deep to the stylohyoid, the course turns posterolateral to enter the
parotid gland, after which it quickly turns superiorly to run posterior to the ramus
of the mandible
- passes superficial to the styloid process, unlike the internal carotid
- has several branches before terminating as the maxillary artery and superficial
temporal artery:
- ascending pharyngeal artery
- ascends along the lateral pharyngeal wall
-supplies the pharynx
- superior thyroid artery
- follows the superior pole of the thyroid to the isthmus where it anastomoses
with the opposite superior thyroid artery and the inferior thyroid arteries
- supplies the thyroid gland and surrounding structures

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 Anterior triangle of the neck
- lecture notes -
- gives rise the superior laryngeal artery (supplies the larynx internally) and a
muscular branch for the sternocleidomastoid)
- lingual artery
- arises posterior to the tip of the greater horn of the hyoid, then turns slightly
superiorly before resuming an anterior direction to travel deep to the
hyoglossus
- at the anterior border of hyoglossus, the artery turns superiorly and
bifurcates on the lateral aspect of genioglossus as the sublingual and deep
lingual arteries
- supplies the posterior tongue and nearby structures
- occasionally arises with the facial artery from a common trunk off the
external carotid artery
- facial artery
- arises anteriorly off the external carotid at the lower border of the posterior
belly of the digastric muscle
- runs a sinuous course in the digastric triangle, deep to the submandibular
gland, until it crosses the inferior margin of the mandible at a point just
anterior to the masseter insertion
- travels in the face anterior to the anterior facial vein
- occasionally arises with the lingual artery from a common trunk off the
external carotid artery
- gives rise to the tonsillar branch (supplies palatine tonsil), the ascending
palatine branch (supplies soft palate), and the submental branch (supplies
structures along its course into the submental triangle, superficial to
mylohyoid)
- occipital artery
- arises posteriorly off the external carotid at the lower border of the posterior
belly of the digastric muscle
- travels along inferior margin of sternocleidomastoid until reaching splenius
capitis, at which point the artery travels deep to the splenius capitis just
inferior to its insertion
- at the medial border of splenius capitis the artery meets the greater occipital
nerve to travel in the subcutaneous tissue up to vertex
- gives rise to a muscular branch of the sternocleidomastoid muscle and a
descending cervical artery (supply neck muscles and anastomose with
thyrocervical and costocervical trunks, as well as vertebral arteries)
- posterior auricular artery
- arises off posterior surface of external carotid superior to the posterior belly
of the digastric and travels along it to the mastoid process and external
auditory meatus
- gives rise to a small branch which travels into the stylomastoid foramen,
otherwise it travels superiorly into the skin posterior to the ear
- internal carotid
- arises from the posterior surface of the common carotid at its bifurcation to travel
primarily anterior to the anterior tubercles of cervical vertebrae
- passes deep to the posterior belly of the digastric after the external carotid artery
does
- passes deep to the styloid process, unlike the external carotid
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 Anterior triangle of the neck
- lecture notes -
- turns lateral to enter the carotid canal at the base of the skull
- has no branches in the neck
- subclavian artery
- enters the neck posterior to sternohyoid and sternothyroid muscles then arches to
passes between scalenus anterior and scalenus medius
- becomes the axillary artery once it crosses the lateral edge of the first rib
- divided into three parts:
- 1st part (origin of subclavian to medial border of scalenus anterior) gives rise
to:
- vertebral artery
- travels in interval between longus colli and scalenus anterior
to enter the 6th transverse (costotransverse) foramen and
ascends through foramena above until it enters the cranial
cavity via the foramen magnum
- undergoes several direction changes in the upper neck
- internal thoracic artery
- thyrocervical trunk
- inferior thyroid artery
- travels posterior to the internal jugular vein until the
cricotracheal junction (lower border of C6) when it
turns medial, passes posterior to the common
carotid and runs to the thyroid gland
- will supply structures along its path, as well as the
thyroid and parathyroid glands
- has an inferior laryngeal branch which enters the
larynx beneath the inferior constrictors
- ascending cervical artery (frequently arises from the thyroid
artery)
- transverse cervical artery
- suprascapular artery
- 2nd part (posterior to scalenus anterior) gives rise to:
- costocervical trunk (variable in origin location)
- supreme (or superior) intercostal artery, which supplies the
1st and 2nd posterior intercostals arteries
- deep cervical artery runs posteriorly over neck of first rib on
its way to the deep surface of semispinalis capitis.
Supplies nearby muscles.
- 3rd part (lateral border of scalenus anterior to the lateral edge of 1st rib)
- veins
- anterior jugular
- lie between external and middle cervical fascia layers
- runs along the medial border of the sternohyoid muscles until just superior to the
sternoclavicular joint
- bifurcates at sternoclavicular joint to send medial branches, which join to the
opposite side (forming jugular venous arch), and lateral branches, which drain to
the external jugular vein

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 Anterior triangle of the neck
- lecture notes -
- a communicating vein often joins the common facial vein to the bifurcation of the
anterior jugular vein by running along the medial border of the
sternocleidomastoid muscle
- internal jugular
- accompanies the common carotid and internal carotid arteries
- receives drainage from most of the veins accompanying arteries off the external
carotid artery
- at the base of the skull it is positioned posterior to the internal carotid artery, but
soon it moves lateral to the artery (and subsequently the common carotid) and
maintains this relationship through much of the neck. Thus it sits in front of the
origins of scalenus medius and scalenus anterior.
- joins the subclavian vein anterior to the first part of the subclavian artery
- external jugular vein
- formed from the union of the posterior division of the retromandibular vein and the
posterior auricular vein
- travels inferiorly across sternocleidomastoid and into the posterior triangle
- superior thyroid vein
- drains into the internal jugular vein
- lingual vein
- drains into the internal jugular vein
- formed from a vein accompanying the lingual artery and one on the superficial
surface of hyoglossus
- (anterior) facial vein
- travels with the anterior artery over the inferior margin of the mandible
- joined by the anterior fork of the retromandibular vein, thus forming the common
facial vein, which pierces the carotid sheath to drain into the internal jugular vein
- posterior auricular vein
- travels with the posterior auricular artery
- joined by the posterior fork of the retromandibular vein, thus forming the external
jugular vein
- occipital vein
- usually drains into the deep cervical vein rather than traveling with the occipital
artery to the anterior neck
- subclavian vein
- joins the internal jugular vein at the medial border of the scalenus anterior
- its only primary tributary in the neck is the external jugular vein, the other veins
that accompany arterial branches off the subclavian artery drain into the
brachiocephalic vein
- middle thyroid vein
- drain by running laterally from the thyroid gland anterior to the intervening portion
the carotid sheath and into the internal jugular vein
- inferior thyroid vein
- several veins drain inferiorly from the thyroid lobes, often coalescing into one or in
some case more than one inferior thyroid vein
- drain into the left brachiocephalic vein
- transverse cervical vein
- accompanies transverse cervical artery
- drains into the external jugular vein
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 Anterior triangle of the neck
- lecture notes -
- suprascapular vein
- accompanies suprascapular artery
- drains into the external jugular vein
- retromandibular vein (also called posterior facial vein)
- runs superficial to the external carotid artery and through the parotid gland
- bifurcates into an anterior and posterior branch near the inferior pole of the parotid
gland

Nerves
- ansa cervicalis (descendens hypoglossi + descendens cervicalis)
- descendens hypoglossi (superior limb)
- C1 fibers that travel with the hypoglossal nerve (XII) until it passes between the
internal carotid artery and the internal jugular vein
- after leaving the hypoglossal nerve (XII), these fibers travel anteriorly in the carotid
sheath
- descendens cervicalis (inferior limb)
- C2-C3 contributions that travel inferiorly
- the two descendens meet just superior to where the intermediate tendon of the omohyoid
crosses anterior to the internal jugular vein
- supplies the infrahyoid (strap) muscles, with the exception of thyrohyoid, which receives
ventral ramus C1 axons coming off the hypoglossal nerve (XII).
- phrenic nerve
- originates from part of the cervical plexus (contributions from C3-C4 ventral rami) and is
joined by contributions from the C5 ventral ramus
- travels inferiorly across scalenus anterior
- facial nerve (VII)
- exits the stylomastoid foramen and gives off three branches within a short distance before
entering the parotid gland:
- communication to the auricular branch of the vagus (probably somatic sensation
from external auditory meatus)
- posterior auricular branch (somatomotor to occipitalis, auricularis posterior, and
auricularis superior)
- nerve to posterior belly of digastric and stylohyoid
- travels lateral to the retromandibular vein within the parotid gland after splitting into
superior and inferior divisions
- glossopharyngeal nerve (IX)
- innervates carotid body and carotid sinus
- vagus nerve (X)
- travels posterior to the internal carotid artery and internal jugular vein, but within the
carotid sheath to leave the neck between the brachiocephalic vein and the 1st part of the
subclavian artery
- superior laryngeal nerve
- arises soon after the vagus nerve (X) passes through the jugular foramen
- divides into:
- internal laryngeal nerve
- travels inferiorly (medial to carotid sheath, lateral to pharynx) until reaching
the greater horn of the hyoid, where it accompanies the superior laryngeal
artery and pierces the thyrohyoid membrane
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 Anterior triangle of the neck
- lecture notes -
- somatic sensory and parasympathetic innervation to the larynx superior to
the vocal cords
- special sensory (taste) for any taste buds on the anterior surface of the
epiglottis
- external laryngeal nerve
- travels down the lateral surface of the pharynx to the cricothyroid muscle
- somatic motor to the cricothyroid muscle and surrounding portions of the
inferior constrictors
- recurrent laryngeal nerves
- travel superiorly in the tracheo-esophageal interval until running deep to the lower
border of the inferior constrictor
- inferior to the isthmus of the thyroid it is medial to the common carotid artery and
outside the sheath, while superior to the isthmus it is separated from the carotid
sheath by the thyroid gland
- inside the larynx, becomes known as the inferior laryngeal nerve
- somatic sensory and parasympathetic innervation to the cervical trachea below the
vocal folds
- somatic motor to all internal laryngeal muscles
- somatic motor, somatic sensory, and parasympathetic innervation to the cervical
esophagus. Note that the cervical esophagus differs from the remainder of the
esophagus since it has skeletal muscle fibers (i.e., it is not entirely smooth
muscle).
- vagal cardiac branches
- often run with sympathetic cervical cardiac nerves to the cardiac plexus
- contain preganglionic parasympathetic axons
- hypoglossal nerve (XII)
- exits the skull through the hypoglossal canal and runs deep to the posterior belly of the
digastric before crossing anterior to the external carotid artery
- as it crosses anterior to the external carotid artery, the occipital artery which is immediately
superior, will send off the muscular branch to the sternocleidomastoid muscle that loops
over the hypoglossal nerve (XII)
- after passing the external carotid artery, the nerve travels on the superficial surface of
hyoglossus deep to the intermediate tendon of the digastric muscle and runs toward the
lateral edge of mylohyoid until it disappears deep to it in order to enter the tongue
- the hyoglossus muscle lies between the deeper lingual artery and the more superficial
hypoglossal nerve (XII)
- joined by C1 fibers almost immediately upon leaving the skull
- sympathetic trunk
- travels over the anterior bars of the transverse processes of cervical vertebrae (cervical
equivalents of ribs in the thorax) and lies on the longus colli and longus capitis muscles
- posterior and medial to the carotid sheath
- splits (forming the ansa subclavia) to pass anterior and posterior to the subclavian artery,
after which it rejoins into a single structure
- three associated ganglia
- superior cervical
- usually lies at the level of C1-C2, or C2-C3
- will send gray rami to upper 3 or 4 cervical ventral rami

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 Anterior triangle of the neck
- lecture notes -
- distribute into the head via arteries, including into the orbit via the internal
carotid sympathetic nerve plexus
- will send postganglionic bundles to:
- visceral organs in neck
- internal carotid sympathetic nerve plexus (vasculature in eyeball,
dilator pupillae, Müller’s muscle, and vascular smooth muscle +
sweat glands on the forehead => frontal nerve)
- external carotid sympathetic nerve plexus (vascular smooth muscle
and sweat glands)
- glossopharyngeal (IX), vagus (X), and hypoglossal (XII)
- middle cervical
- when large enough to observe usually occurs between 4-6th cervical
vertebrae, and where the inferior thyroid artery crosses the sympathetic
trunk
- inferior cervical
- usually lies at or below the 7th cervical vertebra
- may occur on the posterior limb of the ansa subclavia, or just after the two
limbs join
- when fused with the 1st thoracic sympathetic ganglion, this new structure is
called the stellate ganglion
- will send gray rami to cervical ventral rami 6-8
- will send postganglionic bundles to visceral organs in the neck, and possibly
some to the heart as cervical sympathetic cardiac nerves (or as cervical
autonomic cardiac nerves when joining with the vagal cardiac branches)

Lymphatics
- Thoracic duct
- travels lateral to the esophagus until reaching the inferior pole of the thyroid gland when it
then turns lateral passing posterior to the common carotid artery, anterior to the origin of
the vertebral artery, and posterior to the internal jugular vein
- drains into the posterior aspect at the junction of the internal jugular vein and subclavian
veins forming the brachiocephalic vein
- Deep cervical lymph nodes
- all structures superior to the clavicles ultimately (i.e., indirectly or directly) drain to deep
nodes lying posterior to sternocleidomastoid and along the surface of the carotid sheath
next to the internal jugular vein
- the superior belly of the omohyoid crossing the carotid sheath defines the superior group
from the inferior group (alternately called the supraclavicular or scalene nodes)
- superior groups drain to inferior groups which coalesce into a jugular trunk (drains into the
junction of the internal jugular and subclavian veins)
- Superficial lymph nodes in neck draining directing into the deep cervical lymph nodes
- parotid and submandibular nodes are attached to the superficial surfaces of the respective
glands
- submental nodes lie on the surface of mylohyoid in the submental triangle (drain partly to
submandibular nodes and partly to deep cervical nodes

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