Anatomy MCQS

HUMAN ANATOMY Neck

93

NECK 

Cylindrical region connecting Head and Trunk

EXTENT 

Above - lower border of body of mandible, line joining angle of Mandible to Mastoid process, Mastoid process, Superior Nuchal line, External occipital protuberance.



Below - Suprasternal notch of Manubrium sterni, Clavicle, Acromion Process, C7.

LAYERS 

Skin, Superficial fascia with cutaneous vessels nerves and Platysma



Deep fascia is cervical fascia

CUTANEOUS NERVES Branch

Origin

Muscles innervated

Lesser Occipital

C2

Great auricular n

C2, C3

Transverse cervical

C2, C3

Skin of anterior triangle

---

Infrahyoid (MAHE-95)

Ansa cervicalis

Skin of neck, scalp posterosuperior to auricle Skin over parotid gland, posterior auricle, angle of mandible to mastoid process

Phrenic

C3 - C5

Diaphragm

Supraclavicular

C3, C4

Skin over shoulder

CERVICAL FASCIA 

The deep fascia of the neck, divided into three layers – Investing, Pretracheal and Prevertebral



These form natural lines of cleavage through which tissues may be separated, and limit the spread of pus from infections in the neck.

Investing layer of Deep Cervical Fascia Forms a collar around the neck, located between the superficial fascia and the muscular layer Attachments

Features

Superiorly: external occipital protuberance, superior

The investing layer splits to enclose -

nuchal line, mastoid process, lower border of the



2 muscles – Trapezius, Sternocleidomastoid

mandible



2 salivary glands – Parotid, Submandibular

Inferiorly: spine of the scapula, acromion process,



2 spaces – Suprasternal, Supraclavicular

clavicle, manubrium



2 pulleys to bind tendons – Digastric and

Posteriorly: ligamentum nuchae, C7 spine

Omohyoid

Anteriorly: symphysis menti, body of hyoid Pretracheal layer of Deep Cervical Fascia Attachments Superiorly: hyoid bone, oblique thyroid cartilage, cricoid cartilage

Features 

Lies deep to Infrahyoids, splits to enclose thyroid, trachea and esophagus

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HUMAN ANATOMY Neck

94

Inferiorly: arch of the aorta (superior mediastinum) Laterally: fuses with the carotid sheath

Prevertebral layer Attachments

Features 

Superiorly: base of the skull Inferiorly: body of T4 vertebrae

Forms part of a fascial sleeve for the prevertebral muscles



The cervical plexus and proximal parts of the brachial plexus are deep to it; forms floor of posterior triangle of neck, axillary sheath is extension of this fascia

Carotid sheath 

Completely enclosed within investing fascia, on either side of the pretracheal fascia



Encloses the common and internal carotid arteries, internal jugular vein and Vagus nerve (KCET-2010)



The sympathetic chain is located posterior to (and outside) the sheath, ansa cervicalis embedded in ant wall, runs from base of skull to sup mediastinum

Retropharyngeal Space: Potential space between the pretracheal fascia and prevertebral fascia. MIDLINE STRUCTURES OF THE NECK

1.

Fibrous raphe of insertion of Mylohyoid extending from symphysis menti to hyoid bone-derived from 1st branchial arch

2.

Body of the hyoid bone-derived from 2nd, 3rd branchial arches

3.

Median thyrohyoid ligament and Thyrohyoid membrane pierced by Internal Laryngeal nerve and Superior Laryngeal vessels

4.

Laryngeal prominence. Derived from 4th and 6th branchial arches

5.

Cricothyroid ligament, Cricothyroid muscle

6.

Cricoid cartilage

7.

1st tracheal ring

8.

Isthmus and pyramidal lobe of the thyroid gland

9.

Inferior thyroid veins

10. Jugular venous arch (joins the two anterior jugular veins) TRIANGLES OF NECK 

Side of the neck is divided by Sternocleidomastoid into (AIPG-94, 95, 96) 1.

Anterior triangle with apex directed downwards

2.

Posterior triangle with apex directed upwards

ANTERIOR TRIANGLE OF THE NECK (AIPG-2003) Boundaries Base: lower border of mandible, line from the angle of mandible to mastoid process Apex: Jugular notch Anterior border: midline of neck extending from Symphysis menti to Suprasternal notch Posterior border: anterior border of sternocleidomastoid © BRIHASPATHI ACADEMY ‫ ׀‬SUBSCRIBER’S COPY ‫ ׀‬NOT FOR SALE

HUMAN ANATOMY Neck

95

Roof: skin, superficial fascia, investing layer of deep cervical fascia Floor: pharynx, larynx, prevertebral fascia The superior belly of Omohyoid and Digastric muscles divide the anterior triangle into 4 further triangles BOUNDARIES 1. Sides

CONTENTS SUB MENTAL TRIANGLE – MEDIAN TRIANGLE

Anterior bellies of Digastric muscles

Muscles

---

Base

Hyoid bone

Arteries & Veins

---

Apex

Symphysis menti

Nerves

---

Miscellaneous

Sub mental lymph nodes

Floor

Mylohyoid muscle (KCET-03, AIPG-99) 2.

Anterior

DIGASTRIC TRIANGLE Anterior part

Anterior belly of Digastric

Muscles

--Facial artery

Posterior

Arteries & Veins

Posterior belly of Digastric

Mylohyoid vessels

Stylohyoid Nerves

Line from angle to mastoid

Miscellaneous

Muscles

Superficial fascia

Arteries & Veins

Deep fascia Mylohyoid

Nerves

Hyoglossus Middle constrictor of pharynx 3.

Anterosuperiorly

of

Submandibular gland Posterior part

Skin

Floor

part

Submandibular lymph nodes

process

Roof

Mylohyoid nerve Superficial

Base of mandible Base

Facial vein

Miscellaneous

Stylopharyngeus Internal carotid artery Internal jugular vein Hypoglossal nerve (AIPG-99) Vagus nerve Lower pole of parotid gland

CAROTID TRIANGLE

Posterior belly of Digastric

Muscles

Stylohyoid

--Common Carotid Artery and its two terminal branches Branches of External Carotid Artery –

Anteroinferiorly

Superior belly of Omohyoid

Arteries

Superior Thyroid Lingual Facial Ascending pharyngeal Occipital

Posteriorly

Anterior

border

Sternocleidomastoid

of

Veins

Internal tributaries

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Jugular

Vein

and

HUMAN ANATOMY Neck

96

Hypoglossal Ansa cervicalis Skin Roof

Vagus

Superficial fascia

Nerves

Deep fascia

External laryngeal Internal laryngeal Cervical part of Sympathetic trunk

Thyrohyoid Hyoglossus

Floor

Middle and Inferior constrictors

Miscellaneous

---

of pharynx 4. Anterior

Behind

MUSCULAR TRIANGLE

border

Sternocleidomastoid

Infront and above

of



Infrahyoid muscles - These are all innervated by

Posterior belly of Digastric

the Ansa cervicalis except Thyrohyoid, which is

Stylohyoid

innervated by C1 nerve

Infront and below

Superior belly of Omohyoid

Medial

Midline



Surgical approach for thyroid, larynx, trachea and esophagus (deep to this triangle)

Importance of Carotid triangle



Carotid sinus – baroreceptor at the bifurcation of the common carotid, innervated by the sinus branch of IX cranial nerve; Pressure on the carotid sinus  syncope, cessation of heart beat



Carotid body – chemoreceptor posterior to the bifurcation of the common carotid; reflex change in respiration



Important surgical approach for carotid arteries, internal jugular vein, vagus nerve, hypoglossal nerve, cervical sympathetic trunk



Carotid pulse – absence indicates cardiac arrest

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HUMAN ANATOMY Neck

REGION

MUSCLE Mylohyoid

ORIGIN

INSERTION

Mylohyoid line of mandible

Geniohyoid

Inferior

genial

103

INNERVATION

Body of hyoid

tubercle

of

Inferior alveolar

FUNCTION

branch of

Elevate hyoid and floor of

Mandibular nerve (V3)

mouth (KCET-98)

Body of hyoid

C1 (via XII)

Pull hyoid antero-superiorly

Symphysis menti of mandible Suprahyoid

Stylohyoid

Styloid process

Body of hyoid

Facial (VII)

Elevate and retract hyoid

Digastric -

Anterior belly - digastric fossa of

Intermediate tendon-in position

Anterior belly: inferior alveolar

Depress mandible (AIIMS-90)

Mandible

by sling of deep fascia, gap at

(Mandibular branch of V3)

Elevate hyoid

Posterior belly - Mastoid notch of

insertion of Stylohyoid

(APPSC-99, AIPG-99, AIIMS-

2 bellies Anterior,

Posterior

(AIIMS-93, MAHE-94)

Temporal bone to fascial sling (PGI-

03)

2003)

Posterior

belly:

facial

(VII)

(COMEDK-2006) Sternohyoid

Sternoclavicular

joint,

clavicle,

Lower border of body of hyoid

Ansa cervicalis (C1-C3)

Depress hyoid

Posterior surface of manubrium

Oblique

Ansa cervicalis (C1-C3)

Depress hyoid

sterni

cartilage

Oblique line on Thyroid cartilage

Lower border of Body and

C1 (via XII)

Depress hyoid

Ansa cervicalis (C1-C3)

Depress hyoid

manubrium sterni Infrahyoid

Sternothyroid

(AIIMS-06) Thyrohyoid

line

on

Thyroid

greater horn of hyoid Omohyoid –

Inferior belly from superior border

Superior

2 bellies-

of

border of body of hyoid

Superior (near insertion)

notch

scapula

–near

suprascapular

belly

into

inferior

Inferior (near origin) 

Hyoglossus is not included in Suprahyoid muscles

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HUMAN ANATOMY Gross Anatomy

104

POSTERIOR TRIANGLE OF THE NECK Boundaries Apex: superior nuchal line Base: middle 1/3 of clavicle Anteriorly: posterior border of sternocleidomastoid Posteriorly: anterior border of trapezius Roof: skin, superficial fascia, investing cervical fascia Floor: prevertebral fascia (over splenius capitis, levator scapulae, scalenus anterior, medius, posterior) 

Posterior triangle is divided by inferior belly of Omohyoid into

1.

Upper larger Occipital triangle

2.

Lower Supraclavicular / Subclavian triangle

BOUNDARIES

CONTENTS 1.

OCCIPITAL TRIANGLE

Apex

Superior nuchal line

Muscles

Anteriorly

Posterior border of Sternocleidomastoid

Arteries & Veins

--Transverse cervical artery Occipital artery External Jugular Vein

Posteriorly

Spinal accessory nerve

Anterior border of Trapezius

Cutaneous branches of Cervical plexus – Lesser Occipital nerve Great Auricular nerve Transverse Cervical nerve Nerves Base

Inferior belly of Omohyoid

Supra Clavicular nerves Muscular branches – Levator Scapulae Trapezius(C3, 4) Rhomboids (C5) Upper part of Brachial plexus

2. Apex

SUB CLAVIAN TRIANGLE

At junction of sternocleidomastoid and inferior belly of Omohyoid

Muscles

--3rd part of Subclavian artery with its

Anteriorly

Lower

part

of

posterior

Sternocleidomastoid

border

of

branches Arteries & Veins

Subclavian vein Suprascapular artery (thyrocervical trunk)

Posteriorly

3 trunks of brachial plexus

Anterior border of Trapezius

Nerve to Serratus anterior Nerves Base

Middle 1/3 of clavicle

Nerve to Subclavius Suprascapular nerve (last two are branches of upper trunk of brachial plexus)

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HUMAN ANATOMY Gross Anatomy

105

EXTERNAL JUGULAR VEIN (EJV) 

Formed by the union of the Retromandibular and Posterior Auricular Veins (KCET-2000)



Pierces and fuses with investing cervical fascia about 5 cm above clavicle, if cut, fascia prevents it from closing and can cause intravenous air embolus.



It can fill and become visible from holding breath, or from congestive heart failure.



Most of the facial veins drain into the External Jugular Vein.



Transverse Cervical (from back of danger zone) and Supra scapular veins drain into External Jugular vein.

BRACHIAL PLEXUS 

Forms from the anterior rami of cervical nerves C5 to C8 and thoracic nerve T1



The contributions of each of these nerves, which are between the anterior and middle scalene muscles, are the roots of the brachial plexus.



Branches from the roots are dorsal scapular nerve to the rhomboid muscles, long thoracic nerve to the Serratus anterior muscle, nerve to the Subclavius muscle, suprascapular nerve to the supra spinatus and infra spinatus muscles.



As the roots emerge from between these muscles - the anterior rami of C5 and C6 form the upper trunk, the anterior ramus of C7 forms the middle trunk; the anterior rami of C8 and T1 form the lower trunk. The trunks cross the base of the posterior triangle.



Branches from upper trunk are nerve to Subclavius, Suprascapular nerve.



Erb’s point - 6 nerves meet at this point - C5,C6 roots joining to form upper trunk, anterior and posterior branches of upper trunk branches of upper trunk - nerve to Subclavius, Suprascapular nerve. Lesion of this region (forceps delivery, forced expulsion of fetal head in breech delivery) causes Erb’s paralysis.

CERVICAL PLEXUS – C1-C4 

Formed from ventral primary rami of upper four cervical nerves, supplies skin, muscles of neck, and Diaphragm.



All come of Cervical Plexus and penetrate investing fascia of the posterior triangle

Cutaneous nerves 

Lesser occipital nerve (C2-3) – supplies skin of the neck and the scalp posterosuperior to the auricle



Great auricular nerve (C2-3) – supplies skin over the parotid gland, posterior aspect of the auricle and skin extending from the angle of the mandible to the mastoid process



Transverse cervical nerve (C2-3) – skin covering the anterior triangle



Supra Clavicular nerve (C2-4) – skin of the neck, clavicle and anterior shoulder

Phrenic nerve (C3-C4-C5) 

Caries motor, sensory and sympathetic fibers; innervates diaphragm, mediastinal pleura and pericardium.

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HUMAN ANATOMY Gross Anatomy Muscle

Origin Upper

part

Insertion

Innervation

Individually - will

anterior surface of

Lateral one-half of

head

manubrium

superior nuchal line

Sternocleido

sternum

mastoid

Superior surface of

Lateral surface of

(AIPG-09)

medial one-third of

mastoid process

Clavicular head

Function

of

Sternal

of

106

tilt head towards nerve

shoulder on same

[XI] and branches

side rotating head

from anterior rami

to

of C2 to C3 (C4)

opposite side

Accessory

turn

Acting

clavicle

face together

draw

to -

head

forwards Assists in rotating Superior

nuchal

line; occipital Trapezius

the scapula during

external Lateral one-third of

protuberance; ligamentum nuchae; spinous processes of vertebrae

abduction

clavicle;

acromion;

spine of scapula

Motor-accessory

humerus

nerve

horizontal

[XI];

proprioception

-

C3 and C4

Upper

of above

fibers

elevate,

CVII to

fibers

TXII

lower

-

middle -

adduct, fibers

-

depress scapula Superior border of Omohyoid

scapula medial to scapular notch Anterior of

Anterior scalene

the

Inferior border of body of hyoid bone

Ansa

cervicalis;

anterior rami of C1 to C3

Depress the hyoid bone

tubercles transverse

Scalene tubercle and

of

upper surface of rib

to

I

processes vertebrae

CIII

Anterior rami of C4 to C7

Elevation of rib I

CVI Transverse Middle scalene

Upper surface of rib

processes vertebrae

CII

of

I between tubercle

Anterior rami of

to

and

C3 to C7

CVII Posterior of Posterior scalene

for

Elevation of rib I

subclavian artery tubercles transverse

processes vertebrae

groove

of CIV

to

Upper surface of rib

Anterior rami of

II

C5 to C7

Elevation of rib II

CVI Lower

half

of

ligamentum nuchae; Splenius capitis

spinous processes of vertebrae TIV

CVII to

Together Mastoid

process,

skull below lateral one-third

of

superior nuchal line

Posterior middle

rami cervical

nerves

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-

draw

head back-wards Individually - draw and rotate head to one side (turn face to same side)

HUMAN ANATOMY Gross Anatomy

107

SUB OCCIPITAL GROUP OF BACK MUSCLES Muscle Rectus

Origin

capitis

posterior major Rectus

Insertion

Spinous process of axis (C2)

capitis

Lateral

portion

Innervation of

occipital bone below inferior nuchal line

Spinous

process

of

Medial

portion

of

occipital bone below

Posterior ramus of C1 Posterior ramus of

Extension of head Rotation of face to same side as muscle Extension of head

posterior minor

atlas (C1)

Obliquus capitis

Transverse process of

superior

atlas (C1)

Obliquus capitis

Spinous process of axis

Transverse process of

Posterior ramus of

Rotation of face to

inferior

(C2)

atlas (CI)

C1

same side

inferior nuchal line Occipital bone between superior and inferior nuchal lines

C1

Function

Posterior ramus of C1

Extension

of

head

and bends it to same side

The sub occipital muscles are innervated by the posterior ramus of the first cervical nerve, which enters the area between the vertebral artery and the posterior arch of the atlas. The vascular supply to the muscles in this area is from branches of the vertebral and occipital arteries Contents of Sub Occipital Triangle 

Sub occipital nerve, Vertebral artery, Vertebral plexus of veins

BRANCHES OF THE EXTERNAL CAROTID ARTERY (KCET-97, AIPG-2001) Arteries

Supplies Branches from Medial aspect of external carotid artery

Ascending pharyngeal

artery

(AIPG-2003)

Pharyngeal constrictors and Stylopharyngeus muscle, palate, tonsil, pharyngotympanic tube, meninges in posterior cranial fossa Branches from Anterior aspect of external carotid artery

Superior

thyroid

artery

Thyrohyoid muscle, internal structures of the larynx, sternocleidomastoid and cricothyroid muscles, thyroid gland

Lingual

artery

(APPG-1994, 2001)

Muscles of the tongue, palatine tonsil, soft palate, epiglottis, floor of mouth, sublingual gland All structures in the face from the inferior border of the mandible anterior to the masseter

Facial artery

muscle to the medial corner of the eye, soft palate, palatine tonsil, pharyngotympanic tube, submandibular gland (AIPG-92, 98, AIIMS-2001) Branches from Posterior aspect of external carotid artery

Occipital artery Posterior artery

auricular

Sternocleidomastoid muscle, meninges in posterior cranial fossa, mastoid cells, deep muscles of the back, posterior scalp (MAHE-99) Parotid gland and nearby muscles, external ear and scalp posterior to ear, middle and inner ear structures

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HUMAN ANATOMY Gross Anatomy

108

Terminal Branches of external carotid artery (KCET-2001) Superficial temporal

Parotid gland and duct, masseter muscle, lateral face, anterior part of external ear,

artery

temporalis muscle, parietal and temporal fossae External

acoustic

meatus,

lateral

and

medial

surface

of

tympanic

membrane,

temporomandibular joint, dura mater on lateral wall of skull and inner table of cranial Maxillary

artery

(AIPG-94, 95)

bones, trigeminal ganglion and dura in vicinity, mylohyoid muscle, mandibular teeth, skin on chin, temporalis muscle, outer table of bones of skull in temporal fossa, structures in infratemporal fossa, maxillary sinus, upper teeth and gingiva, infra-orbital skin, palate, roof of pharynx, nasal cavity (MAHE-2002)

Muscles Rectus

Origin

capitis

anterior Rectus

capitis

lateralis

Inferior

surface

Insertion of

of

lateral part of atlas and

bone

its transverse process

Inferior

surface

of

Superior

jugular

process

of

transverse process of

Inferior

surface

surface

Function

Branches from anterior rami of C1, C2

of

Anterior tubercle

of

axis of

Tendinous

slips

to

transverse processes of

bone

vertebrae CIII to CVI

head

Atlanto-occipital

to same side Branches from anterior

Branches from anterior rami of C1 to C3

Flex neck

Flexes the head

LYMPH NODES AND THE LYMPHATIC DRAINAGE OF THE HEAD AND NECK Location

Area of drainage-From

To

Superior Horizontal Chain Sub mental nodes

Submandibular nodes Pre auricular (parotid) nodes Post auricular (mastoid) nodes

Sub mental triangle

Submandibular triangle

Skin of chin, lip, floor of

Submandibular nodes

mouth, tip of tongue

or jugular chain

Sub mental nodes, oral

Intermediate jugular

cavity, face, except forehead

nodes, deep posterior

and part of lower lip

cervical nodes

Lateral surface of pinna,

In front of tragus

side of scalp

Deep cervical nodes

Temporal scalp, medial Mastoid process

surface of pinna, external

Deep cervical nodes

auditory meatus Between mastoid process

Occipital nodes

and external occipital

Back of scalp

Deep cervical nodes

protuberance Vertical chain Posterior

Superficial

Along exterior jugular vein

at

Flexes head laterally

rami of C1, C2

basilar part of occipital

Flexes joint

atlas

Body T3, C1-C3

Longus capitis

surface

basilar part of occipital

occipital bone

Longus colli

Anterior

Innervation

Sub parotid nodes, jugular

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Supraclavicular and

HUMAN ANATOMY Gross Anatomy cervical (posterior triangle)

chain, occipital, and mastoid Deep

Along spinal accessory

109

deep cervical nodes

area

nerve

nodes Intermediate (jugular)

All other nodes of neck

nodes Juguloparotid (subparotid)

Angle of mandible, near

nodes

parotid nodes

Jugulodigastric

Junction of common facial

(subdigastric) nodes

and internal jugular veins

Jugulocarotid (bifurcation) nodes

Lymphatic trunks to left and right thoracic ducts

Palatine tonsils

Bifurcation of common carotid artery close to

Tongue, except tip

carotid body

Juguloomohyoid

Crossing of Omohyoid and

(Omohyoid) nodes

internal jugular vein

Tip of tongue

Anterior (visceral) nodes Parapharyngeal nodes

Lateral and posterior wall of pharynx

Paralaryngeal nodes

Lateral wall of larynx

Paratracheal nodes

Lateral wall of trachea

Prelaryngeal (Delphian) nodes

Cricothyroid ligament Anterior wall of trachea

Pretracheal nodes

below isthmus of thyroid gland

Deep face and esophagus

Intermediate nodes

Larynx and thyroid gland

Deep cervical nodes

Thyroid gland, trachea,

Deep cervical and

esophagus

mediastinal nodes

Thyroid gland, pharynx

Deep cervical nodes

Thyroid gland, trachea,

Deep cervical and

esophagus

mediastinal nodes

ROOT OF THE NECK 

The root of the neck is the junction between the neck and thorax



Important structures are the superior thoracic aperture, cervical pleura and scalenus anterior muscle.

Boundaries of the thoracic inlet Posterior: T1 vertebra Lateral: 1st rib and costal cartilage Anterior: Manubrium Contents of the Root of the Neck Nerves

1.

Vagus nerve and recurrent laryngeal nerve

2.

Sympathetic chain

3.

Phrenic nerve (on scalenus anterior, deep to prevertebral fascia)

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HUMAN ANATOMY Gross Anatomy Arteries

1.

Right brachiocephalic trunk (right subclavian, right common carotid posterior to Sternoclavicular joint)

2.

Left Subclavian artery

3.

Left common carotid artery

4.

Subclavian artery (medial, posterior and lateral parts by scalenus anterior) i.

Vertebral artery, internal thoracic artery, thyrocervical trunk

ii.

Costo cervical trunk (from 1st part on the left)

iii. Suprascapular and/or dorsal scapular arteries Veins (unite posterior to Sternoclavicular joint)

1.

Subclavian vein

2.

Internal jugular vein

Lymphatics

1.

Left side – thoracic duct

2.

Right side – Jugular, Subclavian, Broncho mediastinal lymph trunks (right lymphatic duct)

Viscera

1.

Trachea

2.

Oesophagus

3.

Apex of the lung (and pleural cupula)

Muscles

1.

Longus colli

2.

Sternal ends of sternocleidomastoid, Sternohyoid, Sternothyroid

3.

Scalene muscles (marginal)

*****

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HUMAN ANATOMY Gross Anatomy

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