Triangles of Neck

Cervical fascia of neck

FASCIA OF NECK
 Cervical Subcutaneous Tissue
and Platysma
• The cervical subcutaneous tissue (superficial
cervical fascia) is a layer of fatty connective
tissue that lies between the dermis of the skin
and the investing layer of deep cervical fascia.
This tissue is usually thinner than in other
regions, especially anteriorly. It contains
cutaneous nerves, blood and lymphatic vessels,
superficial lymph nodes, and variable amounts of
fat. Anterolaterally, it contains the platysma.
 PLATYSMA
• The platysma (G. flat plate) is a broad, thin sheet of muscle in the
subcutaneous tissue of the neck.
• The external jugular vein (EJV), descending from the angle of the mandible
to the middle of the clavicle, and the main cutaneous nerves of the neck are
deep to the platysma.
• The platysma covers the anterolateral aspect of the neck. Its fibers arise in
the deep fascia covering the superior parts of the deltoid and pectoralis
major muscles and sweep superomedially over the clavicle to the inferior
border of the mandible. The anterior borders of the two muscles decussate
over the chin and blend with the facial muscles.
• Inferiorly, the fibers diverge, leaving a gap anterior to the larynx and
trachea. The platysma is supplied by the cervical branch of CN VII.
• Acting from its superior attachment, the platysma tenses the skin,
producing vertical skin ridges and releasing pressure on the superficial
veins . Men commonly use this action of the platysma when shaving their
necks and when easing tight collars.
• Acting from its inferior attachment, the platysma helps depress the
mandible and draw the corners of the mouth inferiorly, as in a grimace. As a
muscle of facial expression, the platysma serves to convey tension or stress
 Deep Cervical Fascia

• The deep cervical fascia consists of three

fascial layers (sheaths):
– investing, pretracheal, and prevertebral.
These layers support the viscera (e.g., the
thyroid gland), muscles, vessels, and deep
lymph nodes. The deep cervical fascia also
condenses around the common carotid
arteries, internal jugular veins (IJVs), and
vagus nerves to form the carotid sheath
 INVESTING LAYER OF DEEP
CERVICAL FASCIA
• Superiorly, the investing layer of deep
cervical fascia attaches to the:
• Superior nuchal lines of the occipital bone.
• Mastoid processes of the temporal bones.
• Zygomatic arches.
• Inferior border of the mandible.
• Hyoid bone.
• Spinous processes of the cervical
vertebrae
• Inferiorly, the investing layer of deep cervical fascia
attaches to the manubrium, clavicles, and acromions and
spines of the scapulae.
• The investing layer of deep cervical fascia is continuous
posteriorly with covering the C7 spinous process, and
with the nuchal ligament (L. ligamentum nuchae), a
triangular membrane that forms a median fibrous septum
between the muscles of the two sides of the neck.
Inferiorly between the sternal heads of the SCMs and
just superior to the manubrium, the investing layer of
deep cervical fascia remains divided into two layers to
enclose the SCM.
• A suprasternal space lies between these layers. It
encloses the inferior ends of the anterior jugular veins,
the jugular venous arch, fat, and a few deep lymph
nodes.
• Between the cranium (mandible anteriorly
and occipital bone posteriorly) and the
clavicles, the neck is divided into four
major regions based on the usually visible
and/or palpable borders of the large and
relatively superficial SCM and trapezius
muscles, which are contained within the
outermost (investing) layer of deep
cervical fascia.
 PRETRACHEAL LAYER OF DEEP
CERVICAL FASCIA

• The thin pretracheal layer of deep cervical fascia is

limited to the anterior part of the neck. It extends
inferiorly from the hyoid into the thorax, where it blends
with the fibrous pericardium covering the heart.
• The pretracheal layer of fascia includes a thin muscular
part, which encloses the infrahyoid muscles, and a
visceral part, which encloses the thyroid gland, trachea,
and esophagus and is continuous posteriorly and
superiorly with the buccopharyngeal fascia of the
pharynx.
• The pretracheal layer of deep fascia blends laterally with
the carotid sheaths.
 PREVERTEBRAL LAYER OF
DEEP CERVICAL FASCIA
• The prevertebral layer of deep cervical
fascia forms a tubular sheath for the
vertebral column and the muscles
associated with it
 Carotid Sheath.
• The carotid sheath is a tubular fascial investment that
extends from the cranial base to the root of the neck.
This sheath blends anteriorly with the investing and
pretracheal layers of fascia and posteriorly with the
prevertebral layer of fascia. The carotid sheath contains
the:
• Common and internal carotid arteries.
• Internal jugular vein.
• Vagus nerve (CN X).
• Some deep cervical lymph nodes.
• Carotid sinus nerve.
• Sympathetic nerve fibers (carotid periarterial plexuses).
• The carotid sheath and pretracheal fascia communicate freely with
the mediastinum of the thorax inferiorly and the cranial cavity
superiorly. These communications represent potential pathways for
the spread of infection and extravasated blood.
• To allow clear communication regarding the
location of structures, injuries, or pathologies,
the neck is divided into regions. Between the
cranium and the clavicles, the neck is divided
into four major regions based on the usually
visible and/or palpable borders of the large and
relatively superficial SCM and trapezius
muscles, which are contained within the
outermost (investing) layer of deep cervical
fascia
 Sternocleidomastoid Region

• The SCM visibly divides each side of the

neck into the anterior and lateral cervical
regions (anterior and posterior triangles).
The SCM is a broad, strap-like muscle that
has two heads: The rounded tendon of the
sternal head attaches to the manubrium,
and the thick fleshy clavicular head
attaches to the superior surface of the
medial third of the clavicle
• The sternocleidomastoid muscle divides the
neck into the Anterior and the Posterior
triangles.
 Anterior Triangle
• Bounded
▪ Above;body of the
mandible
▪ Posteriorly;
sternocleidomastoid
muscle
▪ Anteriorly; by the
midline
 Subdivision
• Subdivided into
Carotid triangle
Digastric triangle
Submental triangle
Muscular triangle
 Carotid triangle
• Anteroinferiorly; superior
belly of the omohyoid,
• ANTERSUPERIORLY stylohyoid
muscle
• Superiorly; posterior belly of
the digastric
• Posteriorly anterior border of
sternocleidomastoid muscle .
 Contents of carotid triangle
• Carotid sheath
containing common
carotid artery and its
branches
• Internal jugular vein and
its tributaries
• External carotid artery
and some of its
branches;
• Vagus nerve
• Hypoglossal nerve
• superior root of ansa
cervicalis
• Spinal accessory nerve
(CN XI)
• Deep cervical lymph
nodes;
• Branches of cervical
plexus
• Thyroid gland
• Thyroid gland,
• Larynx,
• pharynx
 Submandibular (digastric)
triangle
• is outlined
• Superiorly;
inferior border of the
mandible
• Inferiorly;
anterior and posterior
bellies of the digastric
muscle
 Contents
• Submandibular gland almost fills triangle
• submandibular lymph nodes.
• Hypoglossal nerve.
• Mylohyoid nerve
• Parts of facial artery and vein
 Submental triangle
• is outlined
• Inferiorly; by hyoid bone
• Laterally; anterior belly
of digastric muscle
• The midline
 Contents
• Submental lymph nodes
• Small veins that unite to form anterior
jugular vein
 Muscular triangle
• is outlined by
• Superiorly;the hyoid bone,
• Laterally;
superior belly of omohyoid
muscle
anterior border of
sternocleidomastoid
muscle.
• The midline
 Contents
• Sternothyroid
• Sternohyoid muscles
• Thyroid and parathyroid glands
• Blood supply for head
and neck originating
from the aortic arch,
includes the
• Brachiocephalic
artery
• Left common
carotid
• Left subclavian
artery.
 Arteries of Neck
• Common Carotid Artery

• External Carotid Artery

• Internal Carotid Artery

• Subclavian Artery
 Branches of Common Carotid Artery

▪ External Carotid
Artery

▪ Internal Carotid
Artery
Branches of External Carotid Artery
▪ anterior branches:
▪ Superior thyroid artery
▪ Lingual artery
▪ Facial artery
▪ Posterior branches:
▪ Occipital artery
▪ Posterior auricular artery
▪ Medial branches:
▪ Ascending pharyngeal artery
▪ Terminal branches:
▪ Superficial temporal artery
▪ Maxillary artery
 Internal Carotid Artery

▪ Begins at the level of upper border of thyroid

cartilage
▪ No branches in the neck
▪ Through carotid canal enters into cranial cavity
▪ Supplies brain, eyes, forehead and part of the nose
 Subclavian Artery
Right Subclavian Artery:
▪ Arises from brachiocephalic artery
(Behind right sternoclavicular joint)
▪ At outer border of 1st rib it becomes Axillary Artery
Left Subclavian Artery:
▪ Arises from Arch of Aorta in the thorax
▪ Runs upwards to the root of the neck & arches
laterally
▪ At outer border of 1st rib it becomes Axillary Artery
 st
1 part of Subclavian Artery
Branches:
1. Vertebral artery

▪ CERVICAL BRANCHES:
Spinal and muscular branches in neck
▪ CRANIAL BRANCHES:
Meningeal,posterior spinal,anterior spinal
artery,posterior inferior cerebellar and meduallry
arteries
 st
1 part of Subclavian Artery
Branches:
2. Thyrocervical Trunk

▪ Inferior thyroid
artery
▪ Transverse cervical
artery
▪ Suprascapular artery
 st
1 part of Subclavian Artery

Branches:
3. Internal thoracic artery

▪ Superior epigastric artery

▪ Musculophrenic artery
 nd
2 part of Subclavian Artery

Lies behind the Scalenus anterior

muscle.
Branches:
1. Costocervical trunk

▪ Superior

intercostal artery

▪ Deep cervical
artery
 rd
3 part of Subclavian Artery

Extends from the lateral border of

the Scalenus anterior muscle to the
lateral border of 1st rib.
Branches: (Occasional)
1. Superficial cervical artery

2. Suprascapular artery
 Posterior Triangle
Bounded
▪ Posteriorly; trapezius
muscle
▪ Anteriorly;
sternocleidomastoid
muscle
▪ Inferiorly by the clavicle
 Subdivision
• Subdivided by inferior belly of the omohyoid muscle into
• Above;Occipital triangle
• Below; supraclavicular triangle
 Occipital triangle
• So called because the occipital artery appears in its apex.
• important nerve crossing the occipital triangle is the spinal
accessory nerve (CN XI).
 Contents
• Part of external jugular vein
• Posterior branches of cervical plexus of
nerves
• Spinal accessory nerve (CN XI)
• Trunks of brachial plexus
• Cervicodorsal trunk
• Cervical lymph node
 Omoclavicular (subclavian)
triangle
• is indicated on the
surface of the neck
by the
supraclavicular
fossa.
• The inferior part of the EJV
crosses this triangle.
• The subclavian artery lies
deep in it .
• These vessels are
separated by the investing
layer of deep cervical
fascia.
 Contents
• Subclavian artery (third
part)
• Part of subclavian vein
(sometimes)
• Suprascapular artery
• Supraclavicular lymph
nodes
Thankyou
1. The main landmarks are shown - the
sternocleidomastoid muscle (SCM), its
sternal and clavicular heads, external
jugular vein, the clavicle and jugular
notch. Numbers are for several
routinely used approaches: 1 - anterior;
2 - central; 3 - posterior; 4 -
supraclavicular. Variations are possible,
one may want to find a point between 2
and 4; some guidelines refer it to as a
central inferior approach and so on
(about 3 more puncture points can be
found in guidelines). Note, if you feel
distinct carotid pulsation and even are
able to move the artery medially, you
will not necessarily succeed with IJV
puncture but surely will avoid that of
carotid artery (ICA). Recall the course
of the IJV relatively to ICA - in the
upper neck behind the ICA, in the
middle neck laterally and in the lower
third - in front of ICA joining the
ipsilateral subclavian vein.
 Here we have the classic point for central approach, namely the angle
between the SCM heads. The needle is advanced at the angle of 30-40
degrees towards the ipsilateral nipple. The vein has not been found - change
your direction a little medially or laterally. Remember, the vein is usually
located at 1-3 cm depth, in some slender persons it could be found just
under the skin.
• Indications
• There are multiple indications for percutaneous
internal jugular (IJ) vein central venous catheters
(CVC). Some examples are:
• hemodynamic monitoring
• rapid intravenous volume repletion
• delivering inotropic or vasopressor medications
• antibiotic administration
• long-term IV access
• poor peripheral venous access
• Indications
• Complex or critically ill patients who need continuous hemodynamic
monitoring
• Patients who require secure venous access for the infusion of
agents that are very irritating or that have a very narrow therapeutic
index, and which, therefore, require a very precise rate of delivery
into the circulation (eg, cytotoxic drugs, inotropic agents)
• Patients who require long-term venous access for parenteral
nutrition, chemotherapy, or long-term prophylactic antibiotics
• Patients in whom very frequent blood sampling or access to the
circulation for other reasons is needed
• Patients in whom venous access cannot be secured by any other
route (For information on other vascular access routes, see
the Vascular TechniquesPatients in whom venous access cannot be
secured by any other route (For information on other vascular
access routes, see the Vascular Techniques section of the Clinical
Procedures journal.)
Posterior triangle of neck