Navigating Neck : Important Land marks During Surgery

2. Locating cranial nervesVII, IX-XII
ImportantAnatomic Relationships:Carotid
Artery, Erb’s Point,ThyrocervicalTrunk
Neck LevelI
Neck LevelIIa&b
Neck LevelIV
Neck LevelV
 Drawings from Netter and Photos from ORunless
otherwise specified

3. Where are goodplaces
to identify the
marginal branch ofthe
facial nerve?

4. ~1cm anterior andinferior
toangle of mandible
Atthe mandibular notch
Deep to the fasciaof the
submandibular gland
(superficial level ofdeep
cervical fascia)
Superfical toadventitia of
the facialvein
 Facial vein can be divided
where it crossesthe
posterior digastric and
elevated to protect the nerve
Møller, M. N., & Sørensen,C.H. (2012)

5. What muscledoesthe glossopharyngeal
nervetravel with and innervate?

6. Leave the posterior fossa
through thejugular foramen
Lies with thestylopharyngeus
(which it innervates)
Muscle andnerveenter pharynx
between the lower fibers of the
superior pharyngeal constrictor
and upper fibers of the middle
constrictor
Sensationto the pharynxand
posterior 2/3of the tongue
Also: branch to the tympanic
plexus and thelesser superficial
petrosal nerve (secretomotorto
the parotid)

7. At what level doesthe
superior laryngeal
nerve divide?

8. SLN passesposterior to the
carotid artery at the same
level asthe hypoglossalnerve
Divides into the internal and
external branches just
posterior and inferior to the
greater cornu of the hyoid
 External follows thesuperior
thyroid artery on the inferior
constrictor muscle until it
enters the cricothyroid
 Internal branch follows the
superior laryngeal branch of
the superior thyroid artery until
it pierces the lateral thyrohyoid
membrane

9. Type 1: cross greater than 1
cm above the upper border
of the thyroid gland
 68%
Type 2a: cross within 1 cm
of the upper border of the
thyroid
 11%
Type 2b: cross below the
upper border of the gland
 14%,Vulnerable to injury
when ligatingthe superior
thyroid vascularpedicle
Ozlugedik,S.,Acar,H. I.,Apaydin, N.,Tekdemir,I., Elhan,A.,
& Comert,A. (2007).

10. Type1,nerve running superficial to the IC(23%)
 At risk when ligate the superior thyroid pedicle
Type2: penetrate the muscle 1cm before reaching the
cricothyroid muscle(68%)
Type3:nerve runs deep into the IC(10%)
Ozlugedik,S.,Acar,H. I.,Apaydin, N.,Tekdemir,I., Elhan,A.,
& Comert,A. (2007).

11. Killian-JamiesonTriangle: inferior thyroid artery,
trachea, common carotidartery
Triplanar: inferior constrictor,esophagus, lateral
wall trachea

12. Mohebati,A., & Shaha,A.R.(2012).

13. Mohebati,A., & Shaha,A.R.(2012).

14. Name4 placesto find XI:

15. Retract posterior belly of
the digastric superiorly,
where it crosses superficial
to theIJV
 Anterior to lateral processof
C1
~4cm below themastoid
tip where penetratesthe
deep portion of SCM
Theposterior border of the
SCM
 ~1-2cmsuperiorto Erb’s
Point
At penetration into the
trapezius Lloyd, S.(2007).

16. Where is XI relativeto
the IJV?

17. Vast majority cross
superficial tothe vein
<3%posterior to the
vein
Rare casespass
through thevein
Hinsley, M. L., & Hartig,G.K. (2010).

18. What characterizes shoulder syndrome from
spinal accessory nerveparalysis?

19. Shoulder syndrome: pain, stiffness, drooping,
limited abduction and flexion, aberrant
scapular rotation (scapularwinging)
http://www.msdlatinamerica.com/ebooks/PracticalOrthopaedicSportsMedicineArthrocopy/sid169169.html

20. Weak headturn
Weak shoulder shrug (maybe
preserved based on levator
function)
Weaknessof shoulder
abduction past 90degrees
 Requires upward rotationof
the scapulaby the trapezius
Note:
 more distal injury may spare
function toSCM
 Trapezius derives varyinglevels
of innervation directly from
cervical roots so function may
not be completelyabsent
http://nervesurgery.wustl.edu/so/CaseS
tudies/2011/110325-
1/Pages/default.aspx

21. Where doesthe hypoglossal nervecrossthe
ECA?

22. Hooksaround the external carotid at the take off of the occipital
artery (lateral to both ICA,andECA)
Canbe found at level just superior to greater horn of the hyoid
bone

23. Course ofthe nerve
 Exits skull via the hypoglossal
canal
 Liesdeepto the IJV,ICA,IX,
X,XI
 Curves90 degrees andpasses
between IJV and ICA,
surrounded by ranineveins
▪ Givesbranch toAnsa
 Runssuperficial to ECAand
just inferior to the digastric
 Extends superiorly along the
hyoglossus muscle and into
the genioglossusto the tip of
the tongue

25. What nerve is lateral to both the ICAand ECA?
What 2 nerveslie between the ICAand ECA?

26. CN XII is lateral to both ICAand ECA
CN IX and pharyngeal portion of Xlie between ICA
and ECA

27. What nerve is
demarcated by * ?
*
LesserOccipital
Greater
Auricular
Supraclavicular
c/o Dr.Vanison’sAnatomyQuestions

28. c/o Dr.Vanison’sAnatomyQuestions

29. What arteries crossthe phrenic nerve
laterally?

30. Tranverse cervical and suprascapular arteriescourse
laterally over the surface fo the phrenic nerves

31. Wang,Y.,Ow,T.J.,&
Myers, J.N.(2012).

32. What arethe boundaries of Ia?
Ib?

33. Wang,Y.,Ow,T.J.,&
Myers, J.N.(2012).

34. What is the clinical significance of levelsIa
and Ib (ie when do you dissect Ia)?

35. Drainage patterns
 Ia: lower lip, floor
of mouth, ventral
tongue
 Ib: all otheroral
cavity subsites
Wang,Y.,Ow,T.J.,&
Myers, J.N.(2012).

36. What is the order of
important structures,
from inferior to
superior, that youfind
going under the
mylohyoid when you
lift up the
submandibular gland?
3
2
1
4

37. 1. Hypoglossal
2. Extension of the
submandibular gland
3. Submandibular duct
4. Lingual Nerveand
submandibular
ganglion 3
2
1
4

38. What arethe boundaries of II?What structure
divides it into aand b?

39. Wang,Y.,Ow,T.J.,&
Myers, J.N.(2012).

40. What is the clinical significance between IIa
and IIb (ie when do you dissect IIB)?

41. IIB: oropharynx and nasopharynx drain to IIB
 Therefore should mobilizeXI
Oral cavity, larynx and hypopharynx first
drain to IIaprior to IIb
 May not be necessaryto dissect IIb if IIa not
involved

42. Whereis the jugulodigastric lymph node?

43. Level II node where IJVcrossedby the posterior belly of the digastric
 Normal size <=1.5cm
 Other neck nodes should be <1cm

45. What is deep to the
posterior belly ofthe
digastric?

46. Posterior belly of the
digastric is superficial
to theECA,ICA, IJV,
sympathetic chain,CN
XI, and CNXII
These structures are
anterior totransverse
process ofC1

47. What are the the
surgical versus
radiographic
landmarks for levelII?

48. Surgical: carotid
bifurcation tothe
omohyoid
Radiologic: hyoidbone
to inferior border of
the cricoid
Wang,Y.,Ow,T.J.,&
Myers, J.N.(2012).

49. Where is the thoracic
duct located relativeto
the thyrocervical trunk
and transverse cervical
artery?

50. ThoracicDuct
 Superficial tothe vertebral
artery/vein and
thyrocervical trunk
 Lies at medial border of
anterior scalene left neck,
just anterior to the phrenic
nerve
 Joins venous system atthe
left internal jugular and
left subclavian vein
intersection
Also lymphaticdrainage
into IJV-subclavian
junction onright!

51. Non-surgical options
(low output<500 mL/day)
 Low-fat diet w/ medium-
chain triglycerides
 TPN
 Careful monitoring fluidand
electrolytes
 Drainage of leakage
 Somatostatin analogs suchas
octreotide
 Negative pressurewound
therapy
SurgicalOptions
(> 1L/day,persistant)
 Percutaneous lymphography-
guided thoracic duct
cannulation/embolization
 Surgical repair
 Closure by locoregionalflaps
 VATS/thoracotomy/pleuro-
desis/pleura-venous or pleura-
peritoneal shunts

52. What arethe boundaries of levelV?

53. Boundaries:SCM,
trapezius, clavicle
Divided byomohyoid
 OccipitalTriangle
 Supraclavicular triangle
Wang,Y.,Ow,T.J.,&
Myers, J.N.(2012).

54. What is deep to the
posterior belly ofthe
omohyoid

55. Brachial plexus
IJV
Phrenic
Transverse
cervicalvessels

57. Cervical
Roots
PhrenicNerve
Transverse
Cervical Artery
andVein

58. Batstone, M. D.,Scott, B., Lowe, D., & Rogers,S.N. (2009). Marginal mandibular nerve injury during neck dissection and
its impact on patient perception of appearance. Head &Neck, 31(5), 673–8. doi:10.1002/hed.21013
Cernea,C.R., Ferraz,A. R., Nishio,S.,Dutra,A., Hojaij, F.C.,& dosSantos, L. R.(n.d.). Surgical anatomy of the external
branch of the superior laryngeal nerve. Head &Neck, 14(5), 380–3. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/1399571
Friedman, M., LoSavio, P.,& Ibrahim, H. (2002).Superior laryngeal nerve identification and preservation in
thyroidectomy. Archives of Otolaryngology--Head &Neck Surgery, 128(3), 296–303. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/11886347
Fujimura, I., de Souza, R.R., deCarvalho, C.A. F.,& Rodrigues,A. J.(1990).Amethod for locating the marginal
mandibular branch of the facial nerve in the neck. ClinicalAnatomy, 3(2), 143–147. doi:10.1002/ca.980030207
Hinsley, M. L., & Hartig, G. K. (2010). Anatomic relationship between the spinal accessory nerve and internal jugular vein
in the upper neck. Otolaryngology--Head and Neck Surgery :Official Journal ofAmerican Academy ofOtolaryngology-Head
and NeckSurgery, 143(2), 239–41. doi:10.1016/j.otohns.2010.03.033
Lloyd, S.(2007).Accessory nerve: anatomy and surgical identification. TheJournalofLaryngology andOtology, 121(12),
1118–25.doi:10.1017/S0022215107000461
Mohebati, A., & Shaha, A. R.(2012). Anatomy of thyroid and parathyroid glands and neurovascular relations. Clinical
Anatomy (NewYork,N.Y.),25(1), 19–31.doi:10.1002/ca.21220
Møller, M. N., & Sørensen, C.H. (2012). Risk of marginal mandibular nerve injury in neck dissection. EuropeanArchives of
Oto-Rhino-Laryngology :Official Journal of the European Federationof Oto-Rhino-Laryngological Societies (EUFOS) :
Affiliated with theGermanSociety forOto-Rhino-Laryngology - Head and NeckSurgery, 269(2), 601–5. doi:10.1007/s00405-
011-1610-2
Ozlugedik, S.,Acar, H. I.,Apaydin, N.,Tekdemir, I., Elhan,A., & Comert,A. (2007).Surgical anatomy of the external
branch of the superior laryngeal nerve. ClinicalAnatomy (NewYork,N.Y.),20(4), 387–91. doi:10.1002/ca.20399
Robbins, K.T.,Shaha,A. R., Medina, J.E.,Califano, J.A.,Wolf,G.T.,Ferlito,A., …Day,T.A. (2008). Consensusstatement
on the classification and terminology of neck dissection. Archives ofOtolaryngology--Head &NeckSurgery, 134(5), 536–8.
doi:10.1001/archotol.134.5.536
Sheahan, P.,& Murphy, M. S.(2011).ThyroidTubercle of Zuckerkandl: importance in thyroid surgery. TheLaryngoscope,
121(11), 2335–7.doi:10.1002/lary.22188
Shin,J., & Cunningham, M. (n.d.). Otolaryngology Prep and Practice. SanDiege: Plural Publishing.
Wang,Y.,Ow,T.J., & Myers, J.N. (2012). Pathways for cervical metastasis in malignant neoplasms of the head and neck
region. ClinicalAnatomy (NewYork,N.Y.),25(1), 54–71.doi:10.1002/ca.21249