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Diagnostic Ultrasound: Head and Neck,

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Diagnostic Ultrasound: Head and
Neck

SECOND EDITION

Anil T. Ahuja, MBBS (Bom), MD (Bom),


FRCR, FHKCR, FHKAM (Radiology)
Professor of Diagnostic Radiology & Organ Imaging, Department of
Imaging and Interventional Radiology, Faculty of Medicine, The Chinese
University of Hong Kong, Hong Kong (SAR), China

Eunice Y.L. Dai, MBBS, MRes(Med), FRCR,


FHKCR, FHKAM (Radiology)
Honorary Clinical Assistant Professor, Department of Imaging and
Interventional Radiology, Prince of Wales Hospital, The Chinese University
of Hong Kong, Hong Kong (SAR), China

Evelyn W.K. Tang, MBBS, MRes(Med),


FRCR
Honorary Clinical Tutor, Department of Imaging and Interventional
Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong,
Hong Kong (SAR), China

Carmen C. Cho, MBBS, FRCR, FHKCR,


FHKAM (Radiology)
Honorary Clinical Associate Professor, Department of Imaging and
Interventional Radiology, Prince of Wales Hospital, The Chinese University
of Hong Kong, Hong Kong (SAR), China

K.T. Wong, MBChB, FRCR, FHKCR,


FHKAM (Radiology)
Honorary Clinical Associate Professor, Department of Imaging and
Interventional Radiology, Prince of Wales Hospital, The Chinese University
of Hong Kong, Hong Kong (SAR), China
Table of Contents

Cover image

Title page

Copyright

Dedications

Contributing Authors

Preface

Acknowledgments

Sections

Part I: Anatomy

SECTION 1: HEAD AND NECK


Chapter 1: Neck

Chapter 2: Sublingual/Submental Region

Chapter 3: Submandibular Region

Chapter 4: Parotid Region

Chapter 5: Upper Cervical Level

Chapter 6: Midcervical Level

Chapter 7: Lower Cervical Level and Supraclavicular Fossa

Chapter 8: Posterior Triangle

Chapter 9: Thyroid Gland

Chapter 10: Parathyroid Gland

Chapter 11: Larynx and Hypopharynx

Chapter 12: Cervical Trachea and Esophagus

Chapter 13: Brachial Plexus

Chapter 14: Vagus Nerve


Chapter 15: Cervical Carotid Arteries

Chapter 16: Vertebral Arteries

Chapter 17: Neck Veins

Chapter 18: Cervical Lymph Nodes

Part II: Diagnoses

SECTION 1: INTRODUCTION AND OVERVIEW

Chapter 19: Approach to Head and Neck Sonography

SECTION 2: THYROID AND PARATHYROID

Chapter 20: Differentiated Thyroid Carcinoma

Chapter 21: Medullary Thyroid Carcinoma

Chapter 22: Anaplastic Thyroid Carcinoma

Chapter 23: Thyroid Metastases

Chapter 24: Thyroid Non-Hodgkin Lymphoma


Chapter 25: Multinodular Goiter

Chapter 26: Thyroid Adenoma

Chapter 27: Colloid Cyst of Thyroid

Chapter 28: Hemorrhagic Thyroid Cyst

Chapter 29: Postaspiration Thyroid Nodule

Chapter 30: Hashimoto Thyroiditis

Chapter 31: Graves Disease

Chapter 32: de Quervain Thyroiditis

Chapter 33: Acute Suppurative Thyroiditis

Chapter 34: Ectopic Thyroid

Chapter 35: Parathyroid Adenoma in Visceral Space

Chapter 36: Parathyroid Carcinoma

SECTION 3: LYMPH NODES


Chapter 37: Reactive Adenopathy

Chapter 38: Suppurative Adenopathy

Chapter 39: Tuberculous Adenopathy

Chapter 40: Histiocytic Necrotizing Lymphadenitis (Kikuchi-Fujimoto


Disease)

Chapter 41: Squamous Cell Carcinoma Nodes

Chapter 42: Nodal Differentiated Thyroid Carcinoma

Chapter 43: Systemic Metastases in Neck Nodes

Chapter 44: Non-Hodgkin Lymphoma Nodes

Chapter 45: Castleman Disease

SECTION 4: SALIVARY GLANDS

PAROTID SPACE

Chapter 46: Parotid Benign Mixed Tumor

Chapter 47: Parotid Warthin Tumor


Chapter 48: Parotid Mucoepidermoid Carcinoma

Chapter 49: Parotid Adenoid Cystic Carcinoma

Chapter 50: Parotid Acinic Cell Carcinoma

Chapter 51: Parotid Non-Hodgkin Lymphoma

Chapter 52: Metastatic Disease of Parotid Nodes

Chapter 53: Parotid Lipoma

Chapter 54: Parotid Schwannoma

Chapter 55: Parotid Lymphatic Malformation

Chapter 56: Parotid Venous Vascular Malformation

Chapter 57: Parotid Infantile Hemangioma

Chapter 58: Benign Lymphoepithelial Lesions-HIV

Chapter 59: Acute Parotitis

SUBMANDIBULAR SPACE
Chapter 60: Submandibular Gland Benign Mixed Tumor

Chapter 61: Submandibular Gland Carcinoma

Chapter 62: Submandibular Metastasis

Chapter 63: Salivary Gland Lymphoepithelioma-Like Carcinoma

Chapter 64: Submandibular Sialadenitis

GENERAL LESIONS

Chapter 65: Salivary Gland Tuberculosis

Chapter 66: Sjögren Syndrome

Chapter 67: IgG4-Related Disease in Head & Neck

Chapter 68: Salivary Gland MALToma

Chapter 69: Salivary Gland Amyloidosis

Chapter 70: Kimura Disease

SECTION 5: LUMPS AND BUMPS


CYSTIC

Chapter 71: Ranula

Chapter 72: Dermoid and Epidermoid

Chapter 73: Lymphatic Malformation

Chapter 74: 1st Branchial Cleft Cyst

Chapter 75: 2nd Branchial Cleft Cyst

Chapter 76: Thyroglossal Duct Cyst

Chapter 77: Cervical Thymic Cyst

SOLID

Chapter 78: Carotid Body Paraganglioma

Chapter 79: Infrahyoid Carotid Space Vagus Schwannoma

Chapter 80: Sympathetic Schwannoma

Chapter 81: Brachial Plexus Schwannoma


Chapter 82: Lipoma

Chapter 83: Pilomatrixoma

MISCELLANEOUS

Chapter 84: Sinus Histiocytosis (Rosai-Dorfman)

Chapter 85: Benign Masseter Muscle Hypertrophy

Chapter 86: Masseter Muscle Masses

Chapter 87: Fibromatosis Colli

Chapter 88: Esophagopharyngeal Diverticulum (Zenker)

Chapter 89: Laryngocele

Chapter 90: Cervical Esophageal Carcinoma

Chapter 91: Vocal Cord Paralysis

SECTION 6: VASCULAR

Chapter 92: Parotid Vascular Lesion


Chapter 93: Venous Vascular Malformation

Chapter 94: Jugular Vein Thrombosis

Chapter 95: Carotid Artery Dissection in Neck

Chapter 96: Carotid Stenosis/Occlusion

Chapter 97: Vertebral Stenosis/Occlusion

SECTION 7: POSTTREATMENT CHANGE

Chapter 98: Expected Changes in Neck After Radiation Therapy

Chapter 99: Postsurgical Changes in Neck

SECTION 8: INTERVENTION

Chapter 100: Ultrasound-Guided Intervention

Part III: Differential Diagnoses

SECTION 1: HEAD AND NECK


Chapter 101: Midline Neck Mass

Chapter 102: Cystic Neck Mass

Chapter 103: Nonnodal Solid Neck Mass

Chapter 104: Solid Neck Lymph Node

Chapter 105: Necrotic Neck Lymph Node

Chapter 106: Diffuse Salivary Gland Enlargement

Chapter 107: Focal Salivary Gland Mass

SECTION 2: THYROID AND PARATHYROID

Chapter 108: Diffuse Thyroid Enlargement

Chapter 109: Iso-/Hyperechoic Thyroid Nodule

Chapter 110: Hypoechoic Thyroid Nodule

Chapter 111: Cystic Thyroid Nodule

Chapter 112: Calcified Thyroid Nodule


Chapter 113: Enlarged Parathyroid Gland

INDEX
Copyright
DIAGNOSTIC ULTRASOUND: HEAD AND NECK, SECOND
EDITION
ISBN: 978-0-323-62572-2

Copyright © 2019 by Elsevier. All rights reserved.


No part of this publication may be reproduced or transmitted in any
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This book and the individual contributions contained in it are
protected under copyright by the Publisher (other than as may be
noted herein).

Notices

Practitioners and researchers must always rely on their own


experience and knowledge in evaluating and using any information,
methods, compounds or experiments described herein. Because of
rapid advances in the medical sciences, in particular, independent
verification of diagnoses and drug dosages should be made. To the
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authors, editors or contributors for any injury and/or damage to
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instructions, or ideas contained in the material herein.

Library of Congress Control Number: 2018967204


Cover Designer: Tom M. Olson, BA
Printed in Canada by Friesens, Altona, Manitoba, Canada
Last digit is the print number: 9 8 7 6 5 4 3
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1600 John F. Kennedy Blvd.


Ste 1800
Philadelphia, PA 19103-2899
Dedications

To my late mum and dad, I owe it all to them. I have been


blessed! To Anita, no sister could have sacrificed more for
the success of her brother. The rock in our lives. To the
three girls who make it all worthwhile: My precious wife,
Reann, for her love, support, patience, and tolerance of my
many imperfections, and to my lovely daughters, Sanjali
and Tiana, for the sheer love, joy, happiness, and meaning
they bring to our lives.

ATA

To Professor Ahuja, our respected mentor, for his generous


teaching and inspiration; and to our families, for their
unconditional love and support.

EYLD, EWKT, CCC, KTW


Contributing Authors
Eric K.C. Law, Hons BSc, MBChB, FRCR, FHKCR, FHKAM
(Radiology), Associate Consultant, Department of Imaging and
Interventional Radiology, Prince of Wales Hospital, The Chinese
University of Hong Kong, Hong Kong (SAR), China
Chris S.C. Tsai, MBChB, Resident, Department of Imaging and
Interventional Radiology, Prince of Wales Hospital, Hong Kong
(SAR), China
Carita Tsoi, MBChB, Resident, Department of Imaging and
Interventional Radiology, Prince of Wales Hospital, Hong Kong
(SAR), China
Simon S.M. Wong, MBBS, FRCR, FHKCR, FHKAM
(Radiology), Honorary Clinical Assistant Professor, Department of
Imaging and Interventional Radiology, Prince of Wales Hospital, The
Chinese University of Hong Kong, Hong Kong (SAR), China

Additional Contributors
Kunwar S.S. Bhatia, MBBS, FRCR
Simon S.M. Ho, MBBS, FRCR
Stella Sin Yee Ho, RDMS, RVT, PhD
Yolanda Y.P. Lee, MBChB, FRCR
H.Y. Yuen, MBChB, FRCR
Preface
The role of ultrasound in evaluating abnormalities in the head and
neck is well established. In evaluating thyroid diseases, it is the
investigation of choice, whereas for many other abnormalities
(salivary glands, parathyroid, neck lymph nodes, and nonnodal
masses), it plays a complementary role to other imaging modalities.
What started as static grayscale imaging modality (predominantly
differentiating cystic from solid masses) has expanded to Doppler,
elastography, and contrast-enhanced ultrasound. These advances in
technology have allowed ultrasound to characterize tissue and
accurately detect and predict histology/cytology of head and neck
lesions. In addition, its role in guiding safe needle biopsy has
significantly increased its specificity.
Modern ultrasound lends itself as an ideal tool in the hands of
clinicians. It is far more accurate than palpation, and with its current
capabilities, it readily provides diagnoses for patients’ symptoms at
their first visit to the doctor. Its application/use has therefore
expanded outside the confines of the imaging department; it is now
extensively used by endocrinologists, head and neck surgeons, and
oncologists to monitor treatment change, follow-up with patients, and
guide interventional procedures in the head and neck (such as
chemical or thermal ablation of lesions).
This book was written to provide essential information to those
who practice or who are considering taking up head and neck
ultrasound as their specialty. It focuses on ultrasound, but readers will
find images from other imaging modalities so as to highlight the
importance of multimodality imaging in modern clinical practice.
The second edition could not have been possible without the
continuing help and contribution of friends (authors, sonographers,
graphic designers, etc.) with similar interests. It has given us all an
opportunity to enhance our own knowledge, share experience, and
contribute images. Above all, we are grateful to all the authors and
contributors to the first edition who laid the foundation of this book
and without whose efforts none of our current work could have been
possible. We remain indebted for their hard work and generosity in
sharing their invaluable expertise. We thank the Elsevier production
team in Salt Lake City for their immense patience, constant
encouragement, and professionalism in guiding us through a difficult
task.
We hope this book will find a place in your library and help you in
your daily clinical practice.
Anil T. Ahuja, MBBS (Bom), MD (Bom), FRCR, FHKCR,
FHKAM (Radiology), Professor of Diagnostic Radiology & Organ
Imaging, Department of Imaging and Interventional Radiology, Faculty of
Medicine, The Chinese University of Hong Kong, Hong Kong (SAR), China
Eunice Y.L. Dai, MBBS, MRes(Med), FRCR, FHKCR, FHKAM
(Radiology), Honorary Clinical Assistant Professor, Department of
Imaging and Interventional Radiology, Prince of Wales Hospital, The Chinese
University of Hong Kong, Hong Kong (SAR), China
Evelyn W.K. Tang, MBBS, MRes(Med), FRCR, Honorary Clinical
Tutor, Department of Imaging and Interventional Radiology, Prince of Wales
Hospital, The Chinese University of Hong Kong, Hong Kong (SAR), China
Acknowledgments
Lead Editor
Megg Morin, BA

Text Editors
Arthur G. Gelsinger, MA
Rebecca L. Bluth, BA
Nina I. Bennett, BA
Terry W. Ferrell, MS
Joshua Reynolds, PhD

Image Editors
Jeffrey J. Marmorstone, BS
Lisa A. M. Steadman, BS

Illustrations
Richard Coombs, MS
Lane R. Bennion, MS
Laura C. Wissler, MA

Art Direction and Design


Tom M. Olson, BA

Production Coordinators
Emily C. Fassett, BA
Angela M. G. Terry, BA
Sections
Part I: Anatomy
SECTION 1: HEAD AND NECK

Part II: Diagnoses


SECTION 1: INTRODUCTION AND OVERVIEW
SECTION 2: THYROID AND PARATHYROID
SECTION 3: LYMPH NODES
SECTION 4: SALIVARY GLANDS
SECTION 5: LUMPS AND BUMPS
SECTION 6: VASCULAR
SECTION 7: POSTTREATMENT CHANGE
SECTION 8: INTERVENTION

Part III: Differential Diagnoses


SECTION 1: HEAD AND NECK
SECTION 2: THYROID AND PARATHYROID
PA R T I
Anatomy
OUTLINE

Chapter 1: Neck

Chapter 2: Sublingual/Submental Region

Chapter 3: Submandibular Region

Chapter 4: Parotid Region

Chapter 5: Upper Cervical Level

Chapter 6: Midcervical Level

Chapter 7: Lower Cervical Level and


Supraclavicular Fossa

Chapter 8: Posterior Triangle

Chapter 9: Thyroid Gland

Chapter 10: Parathyroid Gland

Chapter 11: Larynx and Hypopharynx


Chapter 12: Cervical Trachea and Esophagus

Chapter 13: Brachial Plexus

Chapter 14: Vagus Nerve

Chapter 15: Cervical Carotid Arteries

Chapter 16: Vertebral Arteries

Chapter 17: Neck Veins

Chapter 18: Cervical Lymph Nodes


SECTION 1
HEAD AND NECK
OUTLINE

Chapter 1: Neck

Chapter 2: Sublingual/Submental Region

Chapter 3: Submandibular Region

Chapter 4: Parotid Region

Chapter 5: Upper Cervical Level

Chapter 6: Midcervical Level

Chapter 7: Lower Cervical Level and


Supraclavicular Fossa

Chapter 8: Posterior Triangle

Chapter 9: Thyroid Gland

Chapter 10: Parathyroid Gland

Chapter 11: Larynx and Hypopharynx


Chapter 12: Cervical Trachea and Esophagus

Chapter 13: Brachial Plexus

Chapter 14: Vagus Nerve

Chapter 15: Cervical Carotid Arteries

Chapter 16: Vertebral Arteries

Chapter 17: Neck Veins

Chapter 18: Cervical Lymph Nodes


Neck

TERMINOLOGY
Abbreviations
• Suprahyoid neck (SHN)
• Infrahyoid neck (IHN)

Definitions
• SHN: Spaces from skull base to hyoid bone (excluding orbits,
paranasal sinuses, and oral cavity), including parapharyngeal
(PPS), pharyngeal mucosal (PMS), masticator (MS), parotid
(PS), carotid (CS), buccal (BS), retropharyngeal (RPS), and
perivertebral (PVS) spaces
• IHN: Spaces below hyoid bone to thoracic inlet, including
visceral space (VS), posterior cervical space (PCS), anterior
cervical space (ACS), CS, RPS, and PVS

IMAGING ANATOMY
Overview
• Fascial spaces of SHN and IHN are key for cross-sectional
imaging
Concept is difficult to apply with US
• US anatomy is based on division of neck into anterior and
posterior triangles
Anterior triangle: Bounded anteriorly by midline and
posteriorly by posterior margin of sternomastoid
muscle
– Further divided into suprahyoid and
infrahyoid portions
– Suprahyoid portion: Divided by anterior
belly of digastric muscle into submental
and submandibular triangles
– Infrahyoid portion: Divided by superior
belly of omohyoid muscle into muscular
and carotid triangles
Posterior triangle: Bound anteriorly by posterior margin of
sternomastoid muscle and posteriorly by anterior border
of trapezius muscle
– Apex formed by mastoid process, base of
triangle formed by clavicle
– Subdivided by posterior belly of omohyoid
muscle into occipital triangle (superior) and
supraclavicular triangle (inferior)
• Submental region
Key structures include anterior belly of
digastric muscle, mylohyoid, genioglossus
and geniohyoid muscles, sublingual
glands, and lingual artery
• Submandibular region
Key structures include submandibular gland,
mylohyoid muscle, hyoglossus muscle, anterior and
posterior bellies of digastric muscle, facial vein, and
anterior division of retromandibular vein (RMV)
• Parotid region
Key structures include parotid gland, masseter and
buccinator muscles, RMV, and external carotid artery
(ECA)
• Cervical region
Upper cervical region: Skull base to hyoid
bone/carotid bifurcation
– Key structures include internal jugular vein
(IJV), carotid bifurcation, jugulodigastric
node, and posterior belly of digastric
muscle
Midcervical region: Hyoid bone to cricoid cartilage
– Key structures include IJV, common carotid
artery (CCA), vagus nerve, and lymph nodes
Lower cervical region: Cricoid cartilage to clavicle
– Key structures include IJV, CCA, superior belly
of omohyoid, and lymph nodes
• Supraclavicular fossa
Key structures include trapezius,
sternomastoid, omohyoid muscles,
brachial plexus elements, and transverse
cervical nodes
• Posterior triangle
Bordered anteriorly by sternomastoid muscle and
posteriorly by trapezius muscle
Floor formed by scalene muscles, levator scapulae,
and splenius capitis muscles
• Midline
Key structures include hyoid bone, strap muscles,
thyroid, larynx, and tracheal rings

ANATOMY IMAGING ISSUES


Imaging Recommendations
• Use of high-resolution transducers is essential
• Color/power Doppler examination provides useful
supplementary information to grayscale US
• US is very sensitive in identifying abnormalities (and in
characterizing many head and neck soft tissue lesions)
Combination with FNA cytology (FNAC) provides
specificity and increased diagnostic accuracy
• US + FNAC usually provides adequate information for patient
management
• Cross-sectional imaging (CT, MR) may be required for
Large mass, when detailed anatomical extent is not
fully examined by US
Deep-seated lesion with suboptimal US visualization
and evaluation
Preoperative assessment of relevant adjacent
structures (e.g., bone involvement)

Imaging Approaches
• US imaging protocol
Start in submental region by scanning in transverse
plane
Next, scan submandibular region in transverse and
longitudinal/oblique planes
Then scan parotid region in transverse and
longitudinal planes
Now examine upper cervical, midcervical, and lower
cervical regions in transverse plane
Then examine supraclavicular fossa with transducer
held transversely
Now scan posterior triangle transversely along line
drawn from mastoid process to ipsilateral acromion
Finally, scan midline and thyroid gland in both
transverse and longitudinal planes
• This protocol is robust and can be tailored to suit individual
clinical conditions
• Transverse scans quickly identify normal anatomy and detect
abnormalities
• Any abnormality identified is further examined in
longitudinal/oblique planes (grayscale and Doppler)
• In restless children, it may not be possible to follow above
protocol
It would therefore be best to evaluate primary area of
interest 1st, before child becomes uncooperative

GRAPHICS

Schematic diagram shows the protocol for US examination of


the neck with 8 regions scanned in order: (1) submental
region, (2) submandibular region, (3) parotid region, (4) upper
cervical region, (5) midcervical region, (6) lower cervical
region, (7) supraclavicular fossa, and (8) posterior triangle.
The above protocol is robust and helps to adequately
evaluate the neck for common clinical conditions. Note that
deep structures cannot be adequately assessed by US.

Lateral oblique graphic of the neck shows the anatomic


locations of the major nodal groups of the neck. Division of
the internal jugular nodal chain into high, middle, and low
regions is defined by the level of the hyoid bone and cricoid
cartilage. Similarly, the spinal accessory nodal chain is
divided into high and low regions by the level of the cricoid
cartilage.

GRAPHICS

Axial graphic shows the suprahyoid neck spaces at the level


of the oropharynx. The superficial (yellow line), middle (pink
line), and deep (turquoise line) layers of deep cervical fascia
(DCF) outline the suprahyoid neck spaces. Notice that the
lateral borders of the retropharyngeal and danger spaces are
called the alar fascia and represent a slip of the deep layer of
DCF.
Axial graphic depicts the fascia and spaces of the infrahyoid
neck. The 3 layers of DCF are present in the suprahyoid and
infrahyoid neck. The carotid sheath is made up of all 3 layers
of DCF (tricolor line around carotid space). Notice that the
deep layer completely circles the perivertebral space, diving
in laterally to divide it into prevertebral and a paraspinal
components. Although the spaces are not adequately
demonstrated by US, it is important to be familiar with the
concept in order to understand neck anatomy.

TRANSVERSE ULTRASOUND
Standard transverse grayscale US shows the submental
region. The mylohyoid muscle is an important landmark for
the division of the sublingual (deep to mylohyoid muscle) and
submandibular (superficial to mylohyoid muscle) spaces. Part
of the extrinsic muscles of the tongue, including the
geniohyoid and genioglossus, are visualized.
Standard transverse grayscale US shows the submandibular
region. The submandibular gland is the key structure with its
homogeneous echotexture. The gland sits astride the
mylohyoid and posterior belly of the digastric muscles.
Standard transverse grayscale US shows the parotid region.
Note that the deep lobe is obscured by shadowing from the
mandible and cannot be evaluated. The retromandibular vein
serves as a landmark for the intraparotid facial nerve.

TRANSVERSE ULTRASOUND
Standard transverse grayscale US shows the upper cervical
level. Key structures include the internal jugular vein, the
proximal internal and external carotid arteries, and the jugular
chain lymph nodes. The jugulodigastric node is the most
prominent and consistently seen on US.
Standard grayscale US shows the midcervical level. Note that
the vagus nerve is clearly seen on US.
Standard grayscale US shows the lower cervical level. The
thyroid gland is related to the common carotid and internal
jugular vein laterally. The anterior strap muscles (including the
sternohyoid and sternothyroid muscles) and the superior belly
of the omohyoid are clearly visualized.

TRANSVERSE ULTRASOUND
Standard grayscale US shows the supraclavicular fossa. Note
that the trunks of the brachial plexus are consistently seen on
high-resolution US at this site.
Standard transverse grayscale US shows the posterior
triangle. Note that the intermuscular fat plane is visible. The
spinal accessory nerve and lymph nodes are important
contents of the posterior triangle.
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