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Surgical anatomy of neck

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Layers of the neck
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Surgical anatomy of neck

  3. 3. The neck is a biomechanical wonder!  Connects the head to the trunk  Conduit for blood vessels, nerves, and hollow organs  All of these complicated structures are packed in a very narrow area that allows for a great deal of mobility for the head as it moves relative to the ground
  4. 4. FASCIA  The neck is divided into anatomical compartments by strong fascia, which is arranged in layers and tends to align neck structures in bundles. These are real and important anatomical divisions and have great relevance clinically.  The superficial fascia in the neck contains a thin sheet of muscle (the platysma).
  5. 5. Deep Cervical Fascia  Form the boundaries of compartments  Fascial spaces can communicate infection or fluid to other regions of the body  Used as a guide to surgical dissection  Allow the neck structures to glide past one another  Supports the thyroid, lymph nodes and blood vessels
  6. 6. Deep Fascia  an investing layer, which surrounds all structures in the neck;  the prevertebral layer, which surrounds the vertebral column and the deep muscles associated with the back;  the pretracheal layer, which encloses the viscera of the neck; and  the carotid sheaths, which receive a contribution from the other three fascial layers and surround the two major neurovascular bundles on either side of the neck.
  7. 7. Deep Cervical Fascia
  8. 8. Deep Cervical Fascia
  9. 9. Deep Cervical Fascial Spaces  Retropharyngeal - b/n prevertebral and buccopharyngeal  Pretracheal - b/n infrahyoids and trachea  Lateral pharyngeal - lat to pharynx and communicate with RP and SM spaces  Submandibular - below tongue  deep portion above mylohyoid  superficial portion below mylohyoid
  10. 10. Platysma •Muscle of Facial Expression •Innervated by the cervical branch of the facial nerve
  11. 11. Sternocleidomastoid The sternomastoid muscle divides the neck into two anatomical triangles. •Flexes and rotates the head •Innervation is by CN XI
  12. 12. Trapezius •Moves and stabilizes the scapula, extends the head •Innervation is by CNXI
  13. 13. Deep Cervical (Prevertebral) Muscles
  14. 14. Submental Triangle
  15. 15. Submandibular Triangle
  16. 16. Submandibular Abscess in a person with Diabetes
  17. 17. Patient with submandibular space abscess or Ludwig’s angina who required a tracheostomy.
  18. 18. Carotid Triangle
  19. 19. Muscular Triangle
  21. 21. Suprahyoid Muscles
  22. 22. Suprahyoid Muscles (geniohyoid)
  23. 23. Infrahyoid (Strap) Muscles
  24. 24. Actions of Suprahyoid and Infrahyoid Muscles
  25. 25. Branches of the external carotid artery  superior thyroid artery  ascending pharyngeal artery  lingual artery  facial artery  occipital artery  posterior auricular artery  superficial temporal artery  maxillary artery
  26. 26. Veins  Collecting blood from the skull, brain, superficial face, and parts of the neck, the internal jugular vein.  The paired internal jugular veins join with the subclavian veins posterior to the sternal end of the clavicle to form the right and left brachiocephalic veins.  Tributaries to each internal jugular vein include the inferior petrosal sinus, and the facial, lingual, pharyngeal, occipital, superior thyroid, and middle thyroid veins.
  27. 27. Innervation and Venous Drainage of the Neck
  28. 28. PHARYNX  The is a musculofascial half-cylinder that links the oral and nasal cavities in the head to the larynx and esophagus in the neck.  The pharyngeal cavity is a common pathway for air and food.
  29. 29. PHARYNGEAL WALL  The pharyngeal wall is formed by skeletal muscles and by fascia.  Gaps between the muscles are reinforced by the fascia and provide routes for structures to pass through the wall.
  30. 30. Superficial lymphatics of the neck. sme, submental; sma, submandibular; f, facial; ej, external jugular; aj, anterior jugular; o, occipital; m, mastoid; p, parotid.
  31. 31. Deep lymphatics of the neck. IJ, internal jugular chain; SA, spinal accessory chain; TC, transverse cervical chain; dn, Delphian node.
  32. 32. Cervical levels according to Robbins
  33. 33. Classification of Neck Dissections • Classic radical neck dissection remove cervical lymph nodes from levels I to V. • Extended radical neck dissection L.N. I-V +SAN+SCM+IJV L.N VIII reteropharyngeal Hypoglossal N. Carotid A. Skin of neck Modified radical neck dissection type I (MRND-I) selectively preserves the spinal accessory nerve (SAN) MRND-II Preserves SAN + SCM MRND-III preserves SAN+ SCM+ IJV Comprehensive Neck Dissection
  34. 34. Selective Neck Dissection Supraomohyoid neck dissection, lymph nodes at levels I, II, and III for primary tumors of the oral cavity Jugular node dissection levels II, III, and IV for primary tumors of the hypopharynx and larynx Anterolateral neck dissection, lymph nodes at levels I, II, III, and IV for primary tumors of the oral cavity and oropharynx Posterolateral neck dissection Lymph nodes in the suboccipital triangle, posterior triangle of the neck, level V, Central compartment neck dissection, lymph nodes at level VI in the central compartment of the neck adjacent to the thyroid gland and in the tracheoesophageal groove for thyroid cancer
  35. 35. Cervical lymph node groups removed in various types of neck dissection.
  36. 36. The most commonly used incisions for various types of neck dissections. A, Supraomohyoid neck dissection. B, Supraomohyoid neck dissection with a parotidectomy. C, Supraomohyoid neck dissection with extension for submental dissection.
  37. 37. D, Jugular node dissection. E, Comprehensive neck dissection. F, Comprehensive neck dissection with a thyroidectomy.
  42. 42. Pattern of lymphatic flow as demonstrated by Fisch.
  43. 43. PATTERNS OF NECK METASTASIS Primary site First echelon lymph nodes Oral cavity Submandibular gland Sublingual gland • Level I • Level II • Level III Parotid • Preauricular • Periparotid & intraparotid • Level II • Level III • Upper accessory chain Larynx Pharynx • Level II • Level III • Level IV Thyroid • Perithyroid nodes • Tracheoesophageal groove • Level VI
  44. 44. INCISION AND FLAPS OF NECK  Allow adequate exposure of the surgical field.  Assure adequate vascularization of the skin flaps.  Protect the carotid artery if the sternocleidomastoid muscle has to be sacrificed.  Include scars from previous procedures (e.g., surgery, biopsy, etc.).  Consider the location of the primary tumor.  Facilitate the use of reconstructive techniques.  Contemplate the potential need of postoperative radiotherapy.  Produce acceptable cosmetic results.
  45. 45. Some popular skin incisions for functional and selective neck dissection. (A) Gluck incision for unilateral and bilateral neck dissection. B) Double-Y incision of Martin. (C) Single-Y incision (D) Schobinger incision.
  46. 46. E) Conley incision. F) Mac Fee incision. The Mac Fee incision has excellent cosmetic results. (G) H incision.
  47. 47. The double-Y incision of Martin is also popular for functional and selective neck dissection.
  48. 48. The single-Y incision avoids one of the crossings of the double-Y incision but makes the dissection of the supraclavicular fossa difficult.
  49. 49. A popular incision in our practice is the classic Gluck incision For a bilateral functional neck dissection the incision extends between both mastoid tips, crossing the midline at the level of the cricoid arch. This incision allows good exposure when the neck dissection is to be combined with total or partial laryngectomy.
  50. 50. Cutaneous line of incision 1 = manubrium sterni 2 = clavicle 3 = acromioclavicular joint 4 = anterior margin of trapezius muscle 5 = mastoid
  51. 51. Anaplastic thyroid cancer presents as a rapidly enlarging neck mass (A). Establishing a surgical airway can be challenging due to signifi cant tracheal deviation
  52. 52. Low Kocher’s incision for Thyroidectomy A skin incision is made in, or closely paralleling, a low anterior neck skin crease (Kocher’s incision)
  53. 53. Incision for parotidectomy.
  54. 54. A patient with enlargement of the right submandibular salivary gland. The surface markings indicate the angle of the mandible and the proposed line of incision.
  55. 55. Right branchial cyst. Right cervical tuberculous adenitis with central necrosis (scrofula).
  56. 56. Dermoid cyst. Infected thyroglossal duct cyst.