ANATOMY: ANTERIOR TRIANGLE OF THE

NECK

RELATIONS:
SUPERIOR: Inferior border of the mandible (completed by
an imaginary line drawn from the angle of the mandible to
the mastoid process
INFERIOR: Superior border of the clavicle with the
suprasternal notch
ANTERIOR: Median line of the neck
POSTERIOR: Sternocleidomastoid

EXTERNAL JUGULAR VEINS

Palpable structures within the Anterior Triangle of the Neck:

Hyoid Bone
o Lies below the inferior border of the
mandible
Laryngeal Prominence
o Aka PROMINENTIA LARYNGEA, POMMUM
ADAMI, ADAMS APPLE
o Pointed anteriorly
! Projecting the superior angular
process of the thyroid cartilage
o Thyrohyoid Membrane " membrane
between the hyoid bone and thyroid
cartilage
Cricoid Cartilage
o Narrow strip of cartilage below the thyroid
cartilage
o Shaped like a signet ring
! Narrow anteriorly and expands as
it moves posteriorly
o The only complete ring among the
cartilages of the neck
o Carotid tubercle
! Transverse process of the 6th
cervical vertebrae
! Lies lateral to the cricoids
cartilage
! Where the pulsations of the
common carotid artery can be felt
o Cricothyroid cartilage " membrane
between the thyroid cartilage and cricoid
cartilage
Tracheal cartilages
o Cartilages that lie posterior to the thyroid
gland

SUBCUTANEOUS CERVICAL FASCIA

Layer which contains the superficial structures of

the neck including:
o Platysma muscle
o External Jular Vein (EJV)
o Anterior Jugular Vein
o Cervical Plexus
o Superficial Cervical Lymph Nodes

PLATYSMA

Thin sheet of muscle fibers extending from the

anterior chest wall
o Anterior portion of the 2nd rib level
Its fibers reaches up to the inferior labial muscles
and join their insertion to the skin of the lower lip
Innervated by the cervical branch of the Facial
Nerve
Voluntary contraction of muscles: stretch the
overlying skin
o Strong contractions: pulls down the angles
of the lips

Formed by the union of the Posterior division of the

retromandibular vein and the posterior auricular
vein
Commencement: behind the angle of the mandible
Course: crosses vertically downward over the
surface of the SCM, piercing the investing layer of
the deep cervical fascia and drain into the
subclavian vein
Termination: behind the middle portion of the
clavicle

**SUPERFICIAL CERVICAL LYMPH NODES nodes are

closely related to the EJV
ANTERIOR JUGULAR VEINS

Pair of slender veins on each side of the median

line
Drains the veins on the chin
Course: Descends vertically to pierce the investing
layer of the deep cervical fascia above the jugular
notch to join the EJV or subclavian vein
Jugular Arch anastomis of the 2 anterior jugular
veins which lies above the jugular notch

CERVICAL PLEXUS

All branches of the cervical plexus arise behind the

middle part of the SCM and hooks to its posterior
side to emerge anteriorly
Comprised by the anterior rami of C1- C4
o C1 only has a motor component
o C2-C4 are purely sensory nerves
Branches of the Cervical Plexus
o Lesser Occipital Nerve
! C2
! Course: travels upwards along the
posterior border of the SCM to the
apex of the posterior triangle
! Innervates the occipital area
behind the auricle
o Greater Auricular Nerve
! C2 C3
! Course: crosses over the surface
of the SCM
! Innervates:
Angle of the mandible
Mastoid process
Auricle (skin)
Parotid gland

Transverse Cervical/ Anterior Cutaneous

Nerve of the Neck
! C2 C3
! Course: crosses the external
surface of the SCM horizontally
! Innervates the skin of the anterior
neck
Supraclavicular Nerves
! C3 C4
! Course: Courses superficially as a
single stem behind the posterior
border of the SCM, crossing the
lower part of the posterior triangle
! Divides into medial, intermediate
and lateral branches to innervate
skin along the clavicle up to the
pectoralis

DEEP CERVICAL FASCIA

3 layers of the deep cervical fascia:

o Investing layer
o Pretracheal layer
o Prevertebral layer
Composed of fribro-elastic tissue that forms a colar
around the neck
Functions:
o Maintain the relative positions of the
structures
o Prevents the spread of infection to deeper
layers
o Allows mobility of the neck
o Separate different structures of the neck
! Important in surgery to gauge the
depth of the incision made

INVESTING LAYER OF THE DEEP CERVICAL FASCIA

Bony attachments:
o Superior: Hyoid bone and the lower
border of the mandible
o Inferior: Upper border of the manubrium,
along the clavicle to the acromion and
spine of the scapula
! Supraclavicular Space/ Burns
space " located at the
manubrium which contains the
sterna heads and anterior jugular
vein

** PAROTIDEO-MASSETERIC FASCIA ! extension of the

investing layer, covering the side of the face

Structures within the investing layer:

o Sternocleidomastoid
o Trapezius muscle
o Parotid gland
o Submandibular gland
o Lower portion of the Anterior jugular vein
and jugular arch

PRETRACHEAL LAYER OF THE DEEP CERVICAL FASCIA

Attachments:
o Superior: Hyoid bone

Inferior: Descends to the thoracic cavity

to blend with the adventia of great vessels
and the fibrous pericardium
Known as the dangerous area of the neck
because of its direct continuation to the
pericardium
Functions to firmly hold the thyroid gland to the
cartilages lying posterior to it
o Berrys Ligament/ Lateral Thyrohyoid
Ligament " attaches the thyroid gland to
the cartilage; arises from the pretracheal
layer
Extensions of the Pretracheal Layer:
o Carotid Sheath
! Envelops:
Common Carotid Artery
Internal Jugular Vein
Vagus Nerve
! Reaches the base of the skull and
inferiorly into the thoracic cavity
Only the internal carotid
artery carries the carotid
sheath covering
The ECA has no carotid
sheath covering.
o Prethyroid Lamina
! Ensheaths the infrahyoid muscles
and the thyroid gland
! It blends with the pretracheal
layer inferiorly which descends
into the thoracic cavity
o

**The pretracheal fascia blends with the BUCCOPHARYNGEAL FASCIA along this location.
PREVERTEBRAL LAYER OF THE DEEP CERVICAL FASCIA

Deep layer covering the muscles and

neurovascular structures in the posterior triangle
of the neck
Attachment:
o Superior: basilar part of the occipital
bone
o Inferiorly: Joins the fascia of the
posterior mediastinum in the thoracic
cavity
Axillary Sheath " encloses the brachial plexus and
the subclavian artery; arises from the prevertebral
fascia

**The prevertebral layer also blends with the BUCCOPHARYNGEAL FASCIA and the PHARYNGO-BASILAR
FASCIA.
SUBMANDIBULAR TRIANGLE

Relations:
o Superior: Lower border of the mandible
o Inferior: posterior belly of the digastric
and stylohyoid
o Roof: Mylohoid

**The mylohyoid muscle also comprises the floor of the

mouth.

**The bellies of the posterior digastric and stylohyoid

separate the submandibular triangle from the carotid
triangle.

Contents of the Submandibular Triangle:

o Submandibular gland
o External Carotid artery

Submental Triangle:

Small insignificant triangle bound by the two

anterior bellies of the digastrics muscle
The only significance of the submental triangle is
that it contains lymph nodes, fats and small veins
that unite to form the anterior jugular vein
o Commencement of AJV: submental
triangle

CAROTID TRIANGLE

Relations:
o Superior: bellies of the posterior digastric
and stylohyoid
o Posterior: Anterior border of the SCM
o Anterior: Anterior belly of the omohyoid
Contents of the Carotid Triangle
o Common Carotid Artery medially located
o Internal Jugular Vein laterally located
o Vagus Nerve posteriorly located

EXTERNAL CAROTID ARTERY

Lies more antero-medially than the Internal Carotid

Artery
Bifurcation of the Common Carotid Artery "
superior border of the thyroid cartilage
o Termination of Common Carotid Artery:
superior border of the thyroid cartilage
o Commencement of ECA: Superior border
of the thyroid cartilage
Branches of the ECA (8):
o Superior Thyroid Artery
o Facial Artery
o Lingual Artery
o Occipital Artery
o Posterior Auricular Artery
o Ascending Pharyngeal Artery
o Superficial Temporal Artery
o Maxillary Artery
Termination of the ECA: neck of the mandible
o When it gives rise to its 2 terminal
branches, superficial temporal artery and
the maxillary artery

**The ICA does give off any branches externally, only when
it courses through the Carotid Canal of the skull where it
starts to give off branches supplying the brain.
INTERNAL JUGULAR VEIN

Deeper, more posterior branch

Carotid Sinus slight dilatation located at its
commencement
o Commencement: superior border of
thyroid cartilage
Carotid Bodies/ Glomus Caroticum
o Nestling in between the ECA and ICA

Commencemet: dilated bulb in the jugular fossa

Course: Starts off as a dilated bud in the jugular
fossa. It then descends lateral and superficial to
the common carotid artery and external carotid
artery.
Termination: At the level of T1 vertebrae, superior
to the sternoclavicular joint
Drains the deeper veins of the head, common
facial vein and the superior and middle thyroid
veins.
The IJV then joins the subclavian vein that will then
drain into the brachiocephalic vein

Internal(Jugular(Vein(
Subclavian(Vein(

B(rachiocephalic(
Vein(

VAGUS NERVE

INTERNAL CAROTID ARTERY

Composed of chemoreceptor cells

(baroreceptors) from the parasympathetic
nerves of CNIX and sympathetic nerves
from the superior cervical ganglion
Baroreceptors
are
affected
by
hemoconcentrations of O2 and CO2
pressures
which
influences
blood
pressure, cardiac and respiratory rate.

Emerges from the jugular foramen with the CN IX

and XI
Mixed nerve with fibers:
o Afferent and efferent parasympathetic
fibers to the pharynx, esophagus, larynx,
trachea and lungs
! With special fibers to the heart
and abdominal viscera
o Receives efferent fibers from the cranial
portion of CN XI for the innervations of
most voluntary muscles of the larynx and
pharynx
The main trunk of the vagus nerver lies between
the carotid arteries and the internal jugular vein in
the carotid sheath
Gives off 2 branches, superior and inferior cardiac
branches
o Participates in the cardiac plexus
2 ganglia within the jugular fossa:
o Superior ganglion
! Gives off a meningeal and
auricular branch
o Inferior ganglion
! Gives off:
Phayrngeal branch

participates
in
the
pharyngeal plexus (with

CN
IX)
and
also
innervates the pharynx
and soft palate (with
cervical plexus)
Superior Laryngeal Nerve
2 branches of the vagus nerve related to the neck:
o Superior Larnygeal Nerve
o Recurrent Laryngeal Nerve
! Right recurrent laryngeal nerve "
hooks to the subclavian artery
! Left recurrent laryngeal nerve "
hooks to the arch of the aorta

o
o

Suprahyoid group of muscels

Infrahyoid group of muscles

Mylohyoid

Thyrohyoid

Hyoglossys

Sternothyroid

Geniohyoid

Sternohyoid

Stylohyoid

Omohyoid

Superior Laryngeal Nerve:

Descends deep to the ICA which divides into:

o Internal Laryngeal Nerve
! Larger branch
! Afferent fibers from dorsum of
tongue, internal mucosa, pharynx,
larynx and vocal folds
o External Laryngeal Nerve:
! Smaller branch
! Descends alongside the superior
laryngeal artery and superior
laryngeal vein
! Innervates the cricothyroid and
inferior constrictor muscles of the
pharynx

HYPOGLOSSAL NERVE

Composed of motor fibers for the lingual muscles

Course: emerges from the hypoglossal canal and
descends with the ICA and IJV to the level of the
posterior belly of the digastric and stylohyoid where
it joins 1st and 2nd spinal nerves. It then twists
anteriorly, passing above the ECA and ICA to enter
the oral cavity where it distributes its branches to
the different lingual muscels.
Descendens Hypoglossi" The fibers from C1 and
C2 separate from the hypoglossal nerve to
descend lateral to the carotid sheath.
Descendends Cervicalis " fibers forming C2 and
C3
Ansa Cervicalis:
o Union of the descendens hypoglossi and
descendens cervicalis
o Supplies the infrahyoid group of muscles

MUSCULAR TRIANGLE

Pretracheal of Infrahyoud muscles or often

referred to as STRAP MUSCLES
o Flat, thin, narrow slips that cover the
thyroid cartilage and gland
o Ensheathed by the pretracheal layer of the
deep cervical fascia
Contents of the muscular triangle:
o Sternohyoid
o Omohyoid
o Sternothyroid
o Thyrohoid
o Thyroid gland
o Parathyroid gland

Thyroid cartilage, cricoids and tracheal

rings
Recurrent Laryngeal Nerve

Digastric
**All the muscles of the infrahyoid group of muscles are
innervated by the ansa cervicalis EXCEPT the thyrohyoid
muscle which is innervated by C1 of hypoglossal nerve.
THYROID GLAND

H-shaped or butterly-shapedgland
Encapsulated
Attached to the sides of the thyroid, cricothyroid
and upper tracheal cartiages via the prethyroid
layer of fascia
Each of the 2 conical lobes taper into apices that
reaches up to about the middle portion of the
lateral thyroid laminae
Isthmus
o Narrow glandular strip which connects the
2 lobes
o Normally positioned in front of the 2nd and
3rd tracheal cartilage
o Base of the isthmus: in front of the lower
border of the 4th tracheal cartilage
Pyramidal Lobe
o Located slightly to the left of the median
plane
o Attached above the hyoid bone
o Levator glandula thyroidea muscle "
smooth
muscular
tissue
which
impregnates the pyramidal lobe
Blood Supply:
o Superior Thyroid Artery
! Supplies the upper and middle
parts of the thyroid gland on each
side
! Branch of the ECA
o Inferior Thyroid Artery
! Branch of the thyrocervical
branch of the subclavian artery
! Course: from the thyrocervical
trunk of the subclavian artery, it
approaches the posterior border
of the gland at its middle part
! Supplies the inferior portion of
the gland
o Thyroidea Ima
! Arising either from the arch of the
aorta or brachiocephalic trunk
! Supplies the isthmus and base of
the gland

Venous Drainage:
o Superior Thyroid Vein and Middle Thyroid Vein
! Drains into the IJV
o Inferior Thyroid Vein
! Located at the base of the isthmus
! Drains into the brachiocephalic vein

PARATHYROID GLANDS

Oval or circular masses located within the capsule at the posterior border of the lateral lobes of the thyroid gland
Innervated by the superior and middle cervical ganlgiia

CRICOID CARTILAGE

Located below the thyroid cartilage and in front of the 6th cervical vertebra
Articulates with the inferior horn of the thyroid cartilage and is attached by:
o Cricothyroid muscles
! Fibers directed obliquely upwards and is attached to the lower border of the thyroid cartilage
o Cricothyroid membrane
! Connects the 2 cartilages
! A fold of this membrane turns inwards to form the vocal membrane which participates in the formation
of the vocal folds

RECURRENT LARYNGEAL NERVE

Paired slender nerves lodged between the thyroid gland and tracheoesophageal tubes
o Right recurrent laryngeal nerve hooks at the subclavian artery
o Left recurrent laryngeal nerve hooks at the arch of the aorta
Related to the inferior thyroid artery
Innervates the intrinsic muscles of the larynx which move the vocal folds

LYMPHATICS

Located superficial at the lateral side of the cricoids and tracheal cartilages
o Higher nodes receive lymph from the head, parotid and sumandibular and pharynx
o Lower nodes receive lymph from the base of the neck, axilla and upper pectoral area and mammary glands
These two efferent vessels unite and drain into:
o Right Subclavian Vein " drains the right side
o Thoracic Duct " drains the left side

MUSCLES OF THE NECK:

ORIGIN
Sternocleidomastoid

Sternal head

Clavicular
head

Platysma

Anterior surface
manubrium

INSERTION

INNERVATION

ACTION

of

Superior surface of the

medial third of the
clavicle
Fascia of the pectoralis
major and deltoids

Mastoid process and lateral

half of the superior nuchal
line

Spinal Accessory Nerve

Can twist and flex head

on
one
side
or
forwards; 2 muscles in
action
can
raise
thoracic inlet

Inferior border of the

mandible and skin of lower
face

Cervical
branch
Trigeminal nerve

of

Mandibular
branch
trigeminal nerve

of

C2 and C3proprioception

Draws skin of neck

superiorly when teeth
are clenched

Digastric

Ant. Belly

Digastic
mandible

fossa

of

Post. Belly

Mastoid process

Intermediate
tendon
attached to the hyoid bone

Stylohyoid

Styloid process

Hyoid bone

Sternohyoid

Manubrium

Hyoid bone

Depresses
mandible

the

Facial Nerve

Depresses
mandible

the

Ansa cervicalis

Depresses hyoid after

elevation
during

Muscular branch of Facial

nerve

swallowing

Omohyoid

Near the jugular notch

Hyoid bone

Sternothyroid

Psoterior surface
manubrium

Oblique line
cartilage

Thyrohyoid

Oblique line of thyroid

cartilage

of

of

thyroid

Hyoid bone

Ansa cervicalis

Depresses,
retracts
and stedies the hyoid

Ansa cervicalis

Depresses hyoid and

larynx

C1 of CN XII

Depresses hyoid and

elevates larynx

**Injury to the SCM can lead to TORTICHOLIS

**The intermediate tendon of the digastrics arises from the pretracheal layer of the deep cervical fascia
IMPORTANT NEUROVASCULAR STRUCTURES
COMMENCEMENT

TERMINATION

External Jugular Vein

Behind the angle of the mandible

Posterior part of the middle portion of the clavicle

Anterior Jugular Vein

Area of the submental triangle

Above the jugular notch

Internal Jugular Vein

Jugular fossa as a dilated bulb of the

skull

At the level of T1 vertebrae, superior to the

sternoclavicular joint

Right Common Carotid

Artery

Sternoclavicular joint (site of the division

of the right brachiocephalic trunk into
the subclavian and common carotid
arteries

Superior border of the thyroid cartilage

Left Common Carotid

Artery

manubrium

Superior border of the thyroid cartilage

External Carotid Artery

Superior border of the thyroid cartilage

Neck of the mandible

Internal Carotid Artery

Superior border of the thyroid cartilage

Petrous part of the temporal bone

BRANCHES OF THE ECA:

COURSE
Superior Thyroid Artery

Emerging from the anterior side, it descends into the apex of the
thyroid gland

SUPPLIES:
Thyroid gland

Accompanied by the external laryngeal nerve

Facial Artery

Arising deep in the submandibular gland

face

Lingual Artery
Occipital Artery

Emerges from the posterior side close to the posterior border of the
posterior belly of the digastric which ascends to the mastoid

Posterior Auricular Artery

Arising from the posterior side at a higher level that the occipital
artery, proceeding towards the auricle of the ear

Occipital part of the skull

Auricles of the ear and
adjacent parts

Maxillary Artery
Superficial Temporal
Artery
Ascending
PharyngealArtery
Internal Laryngeal Artery

Branch of the superior thyroid artery

Accompanied by the internal laryngeal nerve as it pierces the thyrohyoid membrane to supply internal tissues of the
larynx