Practical lesson 11�dentistry department

Lesson content

Clinical anatomy of the neck region

Blood supply, innervation and lymph outflow of the neck. Exposure of external and common carotid arteries.

Jugular veins ectasia. Surgical treatment

Vagosympathetic block according to O.V. Vyshnevsky and M.N. Burdenko

Surgical treatment of neck wounds. Features of it performing

Clinical anatomy and operative surgery of the neck region

Boundaries

• The upper border of the neck is the lower edge and corner of the lower jaw, the lower edge of the external auditory canal, the mastoid process and linea nuchalis superior.
• From below the neck is limited by a line passing along the upper edges of the jugular notch, clavicle, apex of the acromion and further along the conditional line connecting the acromion with the spinous process of the VII vertebra (vertebra рrотіпепs).

�External landmarks

1 – the angle of the lower jaw,

3 – body of hyoid bone, lateraly– great corner.

4 - thyroid cartilage plates, the place of their connection (Adam's apple).

5 – m. scalenus anterior

6 – m. sternocleidomastoideus

7 – jugular notch

8 - the angle formed by back margin m. sternocleidomastoideus and clavicle, in this place can be pressed to the I rib subclavian artery

9 – trapezius muscle

10 - m. scalenus media

11 – the back margin is – ramus mandibulae

Clinical anatomy of the neck fascia

The first fascia (fascia superficialis colli) is part of the general superficial (subcutaneous) fascia. On the neck it forms the vagina of the subcutaneous muscle of the neck (m. рlatysma).

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The second fascia, or the superficial leaf of the neck's own fascia (lamina superficialis fasciae colli propriae), runs around the entire neck and forms a vagina for the sternocleidomastoid and trapezius muscles, a capsule of the submandibular salivary gland. At the bottom it is attached to the anterior surface of the clavicle and sternum, at the top - to the edge of the mandible, and on the sides by spurs it is connected by transverse processes of the cervical vertebrae: one of these processes connects the second fascia with the heel attached to the transverse processes and the other connects the second fascia with the vagina of the vascular-nervous bundle of the neck, which is also fixed to the transverse processes. On the face, the second fascia of the neck becomes the fascia parotideomasseterica, which forms the capsule of the parotid salivary gland and covers the outside of the masticatory muscle.

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The third fascia, or deep leaf of one's own fascia (lamina profunda fasciae colli propriae), is the aponeurosis omoclavicularis, stretched between the hyoid bone at the top and the posterior surface of the clavicle and sternum at the bottom. The lateral borders of this fascia are the omohyoideus muscles, for which it forms the vagina. The fascia forms vaginas for other muscles lying in front of a larynx, a trachea and a thyroid gland (mm. Sternohyoidei, sternothyreoidei, thyreohyoidei), and by means of the processes connecting it with a vagina of a vascular and nervous bunch of a neck, the third fascia associated with the transverse processes of the lower cervical vertebrae.

The second and third fascia in the midline grow together and form a white line of the neck. It is 2-3 mm wide and does not reach the slit of the sternum; because in the lower part of the neck the second and third fascia diverge, and the second fascia is attached to the anterior surface of the sternum and clavicle, and the third to their posterior surface, a cellular space is formed between them.

The fourth fascial leaf of the neck is called the intracervical fascia (fascia endocervicalis). It consists of two plates: parietal, which covers the neck cavity from the inside, and visceral, which covers the organs of the neck. The parietal plate of the fourth fascia forms the vagina of the vascular-nervous bundle of the neck (vagina vasonervosa) and the septum that separates the vascular components of the bundle - the common carotid artery and the internal jugular vein. Along the course of the vessels, the intracervical fascia descends into the upper mediastinum, giving bundles of fascial fibers to the large vessels and pericardium. The visceral plate of the fourth fascia of the neck passes to the organs of the neck, covering the larynx, trachea, pharynx, esophagus, thyroid gland. The fourth fascia attaches branches to the large veins of the neck, which during aspiration at negative pressure in the veins prevent them from collapsing, so an injury to the neck can lead to air embolism.

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The fifth fascia (fascia prevertebralis) is the part of the parietal leaf fascia endocervicalis, which is located behind the viscera of the neck on the spine. It begins outside the pharynx from the base of the skull, descends into the thoracic cavity, passing in front of the spine. It covers a trunk of a sympathetic nerve and forms vaginas of scalene muscles of a neck (m. scaleni anteriores, medii, posteriores).

On the sides of the fascia extends into the outer cervical triangle and forms the vagina there for mm. scalenus anterior, medius et posterior and vagina for а. і v. subclavia, plexus brachialis. Below fascia prevertebralis transformed to the fascia endothoracica. Covering the subclavian vessels in the area of ​​the scalenius muscles, the fascia extends forward to the clavicle and forms a fascial septum, the supraclavicular fossa, separating from the subclavian. The septum is penetrated by lymphatic vessels connecting the subclavian nodes with the supraclavicular.

Clinical anatomy of the neck region

Neck regions

A – regio suprahyoidea;

1 – trigonum submandibulare;

2 – trigonum submentale;

3 – trigonum Pirogovi.

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Б – regio infrahyoidea;

1 – trigonum caroticum;

2 – trigonum omotracheale;

3 – trigonum omoclaviculare;

4 – trigonum omotrapezoideum;

5 – regio sternocleidomastoidea.

Carotid triangle

Carotid triangle (trigonum caroticum) is a space at the anterior portion of the neck. It is bound by the sternocleidomastoid muscle, by the superior belly of the omohyoid muscle and by the posterior belly of the digastric muscle with the stylohyoideus.

Layers of triangle

• skin
• Subcutaneous tissue
• Superficial fascia with platysma
• Fasciae colli propriae
• Cellulose
• parietal leaflet of the intracervical fascia, which forms the vagina for the vascular-nervous bundle of the neck and deep lymph nodes

• The main vascular-nervous bundle of the neck consists of the internal jugular vein and the common carotid artery, which are located on the sides of the vagus nerve. At the same time the vein with its branches lies most superficially, and the general carotid artery lie deepest.
• At the level of the upper edge of the thyroid cartilage of the larynx, the facial vein flows into the internal jugular vein (v. facialis), facial vein take blood from v. lingualis, v. laryngea superior, v. thyroidea superior.

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The venous network covers the arterial vessels of the triangle, which lie deeper.

Carotid triangle contains common carotid artery with its branches: internal carotid artery and external carotid artery. External carotid artery then gives these branches:

• superior thyroid artery (arteria thyroidea superior);
• lingual artery (arteria lingualis);
• facial artery (arteria facialis);
• occipital artery (arteria occipitalis);
• ascending pharyngeal artery (arteria pharyngea ascendens).
• In the carotid triangle we can also see the hypoglossal nerve, which crosses the bifurcated carotid arteries, and accessory nerve. Behind the carotid arteries and internal jugular vein we can find the vagus nerve and much deeper the sympathetic trunk.

• A. carotis communis go along the bisector of the angle formed by the upper belly of the omohyoide muscle and the sternocleido-mastoid muscle.

On the anterior wall of the artery, in front of the vagina of the main vascular-nervous bundle of the neck (parietal leaflet of the intracervical fascia), obliquely placed the upper root of the cervical loop (radix superior ansae cervicalis), formed by branches I and III of the cervical spinal nerves. This root, connecting here with n. hypoglossus, in its course crosses the external and internal carotid arteries.

Division a. carotis communis on the external and internal carotid arteries most often takes place at the level of the upper edge of the thyroid cartilage. The external carotid artery, in contrast to the internal, which has no branches on the neck, gives a number of branches that go in the following order: a. thyroidea superior, a. lingualis, a. facialis, a. pharyngea ascendens.

Topographically a. carotis externa extends forward and medially and lies more superficially than a. carotis interna, which extends laterally and deeper

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• The carotid reflex zone (Glomus caroticum) is located in the bifurcation of the common carotid artery, which consists of connective tissue and specific cells embedded in it, tightly connected with the outer shell of the carotid artery. Its average size is 3X5 mm. The zone includes the following formations:
• carotid glomus (glomus caroticum),
• carotid sinus (sinus caroticum),
• cervical part of the internal carotid artery,
• branches of the glossopharyngeal nerve,
• vagus nerve,
• sympatic trunk.

Impulses coming from the baro- and chemoreceptors of the carotid reflexogenic zone affect the level of blood pressure and chemical composition of the blood.

Trigonum submandibulare

Boundaries:

• Both belly of m. digastricus
• Lower mandible margin

Layers:

• skin
• superficial fascia + platysma.
• subcutaneous tissue, where several lymph nodes are located and pass ramus colli n. facialis, as well as cutaneous branches of the nerves of the neck (n. transversus colli)
• superficial leaf of fascia colli propria submandibular gland and lymph nodes (nodi lymphatici submentales),
• deep leaf of fascia colli propria
• m.mylohyoideus forming the diaphragm of the oral cavity (diaphragma oris).
• Both belly of m. digastricus and m.stylohyoideus
• n. hyoglossus

3— external carotid artery, 4— facial vein, 5 – facial artery, 6 — back belly of digastric muscle, 7 — m. stylohyoideus, 8 — masseter muscle, 9 — lower jaw, 10 — submandible salivary gland, 11 — anterior belly of digastric muscle, 12— hyoide bone

• Fascia propria formed a sac for submandible gland. The fascia covers anterior belly of m. digastricus, m. mylohyoideus, nodi lymphatici submentales, which lie in the chin triangle and are also located in its area m. geniohyoidei et m. genioglossi.

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1 — hyoid bone, 2 — tendons m. digastricus, 3 — lingual а. et v., 4 — hyoglossus m, 5 — submandibular duct, 6 — m. pterygoideus mediаlis, 7 — lower jaw, 8 — masseter m, 9 — gl. sublingual10 — fascia masseterica, 11 — jaw, 1 2— submandibular lymphatic node, 13—facial vein, 14 —gl. submandibular, 1 5 – fascia propria, 16—lingual nerve.

• The deep section of the suprahyoid region is formed by several muscles covered with a deep leaf fascia propria.
• The most medially located m. mylohyoideus, which, growing along the medial edge with the same muscle on the opposite side, forms a diaphragma oris
• To the body of the hyoid bone is fixed a membrane that separates the anterior and posterior belly of m. digastricus. Near the membrane, the back belly covers m. stylohyoideus, which begins with the styloid process temporal bone and fixed to the great horns of hyoid bone.
• From body and horns of hyoid bone to the tongue tissue go the m. hyoglossus, which lie more deeper.

2 — gL parotidea; 3 — a. facialis; 4 — n. lingiialis; 5 — gl. submandibularis; 6 — ductus submandibularis; 7-а. profunda linguae; 8-а. sublingualis; 9, 18 — n. hypoglossus; 10 — m. digastricus; 13 — a. carotis externa; 15 — a. lingiialis;

The submandibular salivary gland has a capsule formed by a bifurcated leaf of its own fascia of the neck. The outer and inner leaves of the fascia are fixed in accordance with the anterior edge of the mandible and its oblique line (Iinea obliqua). The capsule nowhere fixes the gland and does not give a membrane in its thickness.

Between the gland and its capsule is a cellulose tissue, which often contains lymph nodes and along the duct connects with the tissue of the bottom of the mouth.

Ductus submandibularis begins in its anterior upper part and immediately passes into the gap between m. mylohyoideus and m. hyoglossus, directed under the mucous membrane of the bottom of the mouth. In the same gap, just above the duct, is n. Iipgualis, below the duct are located n. hypoglossus and v. lingualis.

Blood suply.

In the thickness of the mandibular gland is the facial artery, which is adjacent to the inner surface of the gland. Its outer surface is often in contact with the vein of the same name, which, bending over the edge of the mandible, goes under the capsule of the gland in the direction of v. internal jugular. At the anterior edge of the so-called masseter, leaving the gland, a. facialis bends over the edge of the mandible and passes into the medial parts of the face.

Glandula submandibularіs

Lingual Pirogov’s triangl

borders:

- Tendon membranes of m.digastricus,

- Back margin of m.mylohyoideus

• n. hypoglossus.
• Base of triangl is n. hyoglossus.

Inside this triangle, you can expose and ligate the lingual artery it located above m.hyoglossus.

�Pirogov's triangle

• 4 n. Hypoglossus et a. Lingualis
• 5 n. Vagus et v. Jugularis int
• 6 a. Laryngea sup.
• 7 a. Carotis ext. Et a. Thyroidea sup
• 8 a. Carotis communis
• 10 m. Masseter et r. Marginalis mandibulae n. Facialis
• 11 a. Et v. Facialis
• 15 m. Mylohyoideus
• 16 M. Mylohyoideus et venter anterior m. Digastirci
• 17 M. Hyoglossus et a. Lingualis
• 18 N. Lingualis *
• 19 N. Hypoglossus
• 20 M. Geniohyoideus
• 21 m.Digastricus venter ant.
• 22 gl. Submandibularis et ductus submandibularis

Trigonum submentale

Boundaries

• Both belly of m. digastricus
• Body of hyoid bone

Layers

• Skin
• superficial fascia with platysma.
• subcutaneous tissue with branches of n. transversus colli
• fascia propria
• m.mylohyoideus which formed oral diaphragm (diaphragma oris).
• m. geniohyoidei
• m. genioglossi

Trigonum submentale

1- cornu minus et corpus ossis hyoideum. 2 - m. hyoglossus, 3 - mandibula et n. alveolaris inf. 4 - m. geniohyoideus, 5 - m. genioglossus, 6 - m. stylohyoideus, 7 - m. mylohyoideus, 8 - m. digastncus - venter ant., 9 - os hyoideum, 10 – mandibula, 11 - tendo m. digastric

Regio sternocleidomasteidea

Boundaries are determined by size and location of the m.sternocleidomastoideus

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layers

• skin
• Subcutaneous tissue
• Superficial fascia and platysma
• Cellulose which contane
• jugularis externa
• Branches of cervical plexus:
• п. occipitalis minor, which innervated skin of occipital region,
• п. auricularis magnus, which take part in innervation of the facial skin, auricle and parotid gland
• п. transversus colli
• Fascia propria
• m. sternocleidomastoideus and lymph nodes, which take the lymph from the facial region and neck organs
• Fascia propria
• Parietal leaf of IVth fascia or prevertebral fascia

Regio sternocleidomasteidea

Upper region contain

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a. carotis communis (7),

• п. Accessorius (15)
• v. jugularis interna (4)
• Truncus n. vagus (6), it formed ganglion inferius.
• There formed n. laryngeus superior, it goes down, on the back of a. carotis interna and gives branches to sympatic trunc.

Segio sternocleidomasteidea

On the lower part of the regio sternocleidomastoidea located spatium antescalenum — between m. scalenus anterior (33) and m. ternocleidomastoideus

On the lower part of the spatium antescalenum join internal and external jugular and subclavian veins (34) there are formed left and right venous corners.

To the left venous corner enter thoracic duct (ductus thoracicus),

To the right— ductus lymphaticus dexter, which is formed by jugular, subclavian and brachiocephalic trunks.

Along the т. scalenus anterior (33) go down to n. phrenicus (32), which go out from cervical plexus

Spatium antescalenum contain:

- a. subclavia

- plexus brachialis

In the upper parts of the area under the prevertebral fascia of the neck located the truncus sympathicus, one of it ganglion is - ganglion cervicale medium (44). From sympathic trunc, started branches outward and upward which connect with the branches of the cervical plexus, formed by the anterior branches of the first four cervical spinal nerves, located deeper prevertebral neck fascia. From the cervical plexus going out n. occipitalis minor (46), n. auricularis magnus, п. transversus colli, n. phrenicus і nn. supraclaviculars.

Trigonum colli laterale

Boundares of the lateral triangle

- Back margin of the m. sternocleidomastoideus,

- Upper external margin of the m. trapezius,

- upper clavicle margin

Lateral triangle contain:

Тrigonum omotrapezoideum

- Margin of the m. trapezius,

- Lower belly of the m. omohyoideus,

- Back margin on the upper part m. sternocleidomastoideus,

Inside of this triangle performing the vagosympathic blocked by Vishnevskiy, anesthesia of the cervical plexus, at the left side performed a surgical access to esophagus and performed incisions when deep phlegmon of the neck occurs

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Тrigonum omoclaviculare,

- clavicle,

- Lower belly m. omohyoideus

• Back margin on the lower part m. sternocleidomastoideus.
• On the trigonum omoclaviculare performed the access to the a., v. subclavіa, to phrenic nerves, anesthesia of brachial plexus (by Kulenkampf) – surgery on the upper limbі, access to the left lymphatic thorax duct.

layers

• skin
• Subcutaneous tissue
• Superficial fascia
• Fascia propria

Fat layer with v. transversa scapulae and v. jugularis externa, which bring blood to v. jugularis interna.

Aponeurosis omoclaviculare (inside borders of the trigonum omoclaviculare)

Cellular spaces

On the trigonum omotrapezoideum region, between the fascia propria and prevertebralis located n. accessorius and lymph nodes.

Inside the borders of the trigonum omoclaviculare located vascular-nervous bundle of the lateral neck triangle

The vascular-nervous bundle consists of subclavian veins and arteries (a. et v. subclavia) and brachial plexus (plexus brachialis)

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• Subclavian artery going to the leteral triangle region from spatium interscalenum and located in cellular between lateral margin of m. scalleni anterior and I rib. On the lateral part of trigonum omoclaviculare subclavian artery goes oblique down and on the middle level of clavicle lies between clavicle and I rib.
• In this place from it start а. transversa colli, a. cervicalis superficialis, a. suprascapularis.

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• The bracheal plexus is formed by the anterior branches of the four lower cervical and first thoracic spinal nerves. They go between anterior and middle scaleni muscles and on the neck (on subclavian part of plexus) there are formed three nervous trunks: truncus superior, medius et inferior. The upper trunk of the plexus is formed by the fusion of the fifth - sixth cervical, middle - the seventh cervical and lower - the eighth cervical and first thoracic spinal nerves.

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In front and below the subclavian artery is the subclavian vein, which is directed to the spatium antescalenum. The vein is separated from the artery by the anterior scalene muscle

Regio сеrvicis роsterior

• Borders

Above - a horizontal line passing the occipital elevation (protuberantia осcipitalis externa) and linea nuchae superior

below - a horizontal line passing through the spinal process of the VII cervical vertebra;

on the sides, the boundary between the anterior and posterior regions runs along the outer edge of the trapezius muscle.

• The sides of the area are separated by a dense leaf fascia, which is a continuation of the neck's own fascia, and the vertebral fascia.

Layers structure

• 1. skin.
• 2. panniculus adiposus (fat)
• 3. fascia superficialis
• 4. lamina superficialis fasciae colli propriae
• 5. m. trapezius

Start from linia nuchae superior, protuberantia осcipitalis externa and cervical and thoracic spinal process – fixed to the clavicle, acromial process and spine of scapula. Innervation by n. асcessorius.

• 6. lamina profunda fasciae colli propriae
• 7. Subtrapezoid space - a layer of dense tissue containing a venous plexus formed by the branches of the vertebral vein (v. vertebralis).

The second layer of muscles

• m. spienii, capitis et сеrvicis
• m. levator scapulae),
• m. rhomboidei, major et minor
• m. serratus . роsterior superior

The 3th layer of muscles

• mm. semispinales, capitis et сеrvicis
• m. longissimi, capitis et сеrvicis

The 4^th layer of muscles

• m. rectus capitis роsterior major
• m. rectus capitis роsterior minor
• m. obliquus capitis superior
• m. obliquus capitis inferior

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Regio сеrvicis роsterior

Layered structure

• m. multifidus
• pars сеrvicatis columnae vertebralis consist of 7 cervical vertebrae. Spinal process of them connect between each other by lig. nuchae, between vertebral arches straight the flavum ligament (ligamenta flava).

Arterial blood supply of the back neck region

1. а. oсcipitalis situated in sulcus mastoid process and after going through mm. splenii capitis et сеrvicis entered to the back neck surfaces

2. а. сеrvicalis profunda rises up and penetrates between the transverse process of the VII cervical vertebra and the I rib

• а. vertebralis go out from hole in transvers process of cervical vertebrae (foramina procesus transversaria) come to the II cervical vertebrae and deviates inward, goes into the opening of the atlant process, then into the furrow of the vertebral artery over the posterior arch of the atlant. Next, the artery passes through the posterior atlanto-occipital membrane and goes through a large occipital foramen into the cranial cavity.

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The vertebral artery first rises vertically, then assumes a horizontal position, then goes up again and goes into the cranial cavity through the large occipital foramen.

Venous outflow from the back neck region

Venous outflow is carried out basically on the same names veins to і. jugularis externa.

General review of the neck arteries

Clinical anatomy of carotid artery. �Exposure and ligation of external carotid arteries. �

A. carotis communis divide to а. carotis externa end а. carotis interna.

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In the area of ​​biurcation is the carotid sinus (sinus caroticus), which contains baroreceptors, and the carotid glomus (glomus caroticum), which contains chemoreceptors that form a sinocarotid reflexogenic zone.

Impulse from the receptors of the carotid sinus and glomus on the sinus branch of the glossopharyngeal nerve (p. sinus carotid n. glossopharyngei) are transmitted

into the central nervous system

Branches of external carotid artery:

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1. а. thyroidea superior

2. а. linguais

3. а. facialis

4. а. pharyngea ascendens

5. а. auricularis роsterior

6. а. осcipitalis

Surgical access to external carotid artery inside the carotid triangle of the neck

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Differences between external and internal carotid arteries:

1. The external carotid artery in the neck gives branches, the internal carotid artery – no
2. The external carotid artery is located inward and in front of the internal, the internal carotid artery is laterally and posteriorly to the external.
3. The external carotid artery is crossed at a distance of 1.5–2 cm from the bifurcation by the sublingual nerve, which runs in the transverse direction and is tangent to the external carotid artery
4. If during operation we put soft clamp for on one of vessels of a carotid bifurcation and pulsation disappears on а. temporalis supetficialis or а. facialis, it is means that we press external carotid artery

• Movie 1

Surgical access to carotid artery 5 min

Exposure and ligation of a. lingualis

Trigonum linguale

limited:

- tendon membrane of m.digastricus,

- posterior edge of m.mylohyoideus

- n. hypoglossus.

The bottom of the triangle is n. hyoglossus.

Within this triangle, the lingual artery, which is located above the m.hyoglossus, can be exposed and ligated.

Pirogov’s triangl

• 4 n. Hypoglossus et a. Lingualis
• 5 n. Vagus et v. Jugularis int
• 6 a. Laryngea sup.
• 7 a. Carotis ext. Et a. Thyroidea sup
• 8 a. Carotis communis
• 10 m. Masseter et r. Marginalis mandibulae n. Facialis
• 11 a. Et v. Facialis
• 15 m. Mylohyoideus
• 16 M. Mylohyoideus et venter anterior m. Digastirci
• 17 M. Hyoglossus et a. Lingualis
• 18 N. Lingualis *
• 19 N. Hypoglossus
• 20 M. Geniohyoideus
• 21 m.Digastricus venter ant.
• 22 gl. Submandibularis et ductus submandibularis

Exposure of the lingual artery

Clinical anatomy of a. subclavia

Clinical anatomy of а. subclavia

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Start to the right of truncus brachiocephalicus and left from arcus аоrtae.

Branches:

1. а. Vertebralis going upper and between the scalenus anterior muscle and m.longus of the neck to hole of transvers proces of VI cervical vertebrae.

2. а. thoracica interna goes down behind the vena subclavia, passes through the upper aperture of the thorax, lies on the posterior surface of the cartilage of the ribs at a distance of 1-2 cm from the edge of the sternum

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3. Truncus thyrocervicalis departs at the medial margin m. scalenus anerior and goes up and gives branches:

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• а. thyroidea inferior go goes up the front surface of m. scalenus anterior

at level VI of the cervical vertebra turns in the medial direction and, behind the common carotid artery, approaches the thyroid gland

• а. сеrvicalis ascendens goes up the front surface m. scalenus anterior and supplies blood to the deep muscles of the neck
• а. сеrvicalis superftcialis in the transverse direction crosses the brachial plexus above the clavicle within fossa supraclavicularis major.

4.а. suprascapularis goes in the transverse direction along the clavicle and reaches the incisura scapulae, overturns over the upper transverse ligament of the scapula and branches within m. infraspinatus.

5.truncus costocervicalis, going up to cupola of pleura and divides into two end branches.

• а. сеrvicalis profunda goes back and penetrates between the I rib and the transverse process of the VII cervical vertebra in the posterior region of the neck and, rising up, gives branches to the local muscles.
• - а. intercostalis supremo crossing around the neck of I rib goes to the first intercostal space, provides blood supply. Often gives a branch for the second intercostal space.

4

6. а. transversa colli —penetrate between brahial plexus truncs goes on trunsverse direction above clavicle and divide for 2 branches:

• ramus superftcialis goes up along the m. levator scapulae
• ramus profundus goes down along middle rnargo medialis scapulae between rhomboid muscle and post.sup. serratus muscles and branching into rhomboids and supraspinatus muscles. It is important for the development of the initial blood circulation in the upper extremities. The subclavian artery in children is located low and is difficult to access from the supraclavicular fossa.

General review of the neck veins

Superficial veins of the neck

1. v. Jugularis externa formed by v. auricularis роsterior and v. retromandibularis. In the supraclavicular fossa flows to angulus venosus Juguli
2. v. Jugularis anterior - small, formed from the saphenous veins of the chin, descends at some distance from the midline of the neck. In the lower parts of the neck, the right and left anterior jugular veins form an anastomosis called the jugular venous arch (arcus venosus juguli). Then the vein goes under the sternocleidomastoid muscle and flows, as a rule, into the external jugular vein.
3. v. mediana colli

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Nota bene!

the pressure in the veins of the neck is negative, so even with small injuries of the veins of the neck suck air, which can lead to air embolism and death of the patient. For this reason, when treating neck wounds, it is first necessary to bandage both the central and peripheral ends of the cuted veins

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Deep veins of the neck - the main collectors are: internal jugular vein, external jugular vein, spinal vein, deep jugular vein

Jugular veins ectasia. �Surgical intervention

Surgery for varicose jugular veins

Plexus and nerves of the neck. General review.

PLEXUS СЕRVICALIS formed by the anterior branches of the 4 upper cervical nerves. After exit through the intervertebral foramen (foramen intervertebrale), these nerves lie on the anterior surface of the deep muscles of the neck at the level of the upper four cervical vertebrae behind the sternocleidomastoid muscle. The cervical plexus forms sensitive, motor (muscular) and mixed branches.

Clinical anatomy of sensitive branches cervical plexus

Sensitive branches form the cutaneous nerves of the neck:

transverse nerve of the neck (1)

medial supraclavicular nerve (2)

intermediate supraclavicular nerve (3)

lateral supraclavicular nerve (4)

great auricular nerve (5)

small occipital nerve (6)

6

5

6

5

4

3

2

1

Clinical anatomy of motor branches cervical plexus

Rami musculares plexus сеrvicalis gives innervation for:

• mm. scaleni anterior, medius et роsterior
• m. longus capitis et colli
• m. rectus capitis anterior
• et m. rectus capitis lateralis
• m. intertransversarii anteriores сеrvicis
• m. levator scapulae

Clinical anatomy of the motor branches of the cervical plexus

To the motor branches make the cervical loop (ansa cervicalis), which is formed at the connection of the upper root (radix superior) and the lower root (radix inferior).

The upper root is formed from 1 cervical spinal nerve, which joins the hypoglossal nerve, is passed under the surface of the carotid artery. The lower root of 2 -3 cervical nerves. Branches depart from the cervical loop to:

• m. sternohyoideus,
• m. sternothyroideus,
• m. thyrohyoideus
• m. omohyoideus

Clinical anatomy of mixed branches of the cervical plexus

• n. phrenicus (mixed) formed by anterior branches of С3-C4, goes down frontal surfaces of m. scaleni to mediastinum and on the lateral surfaces of pericarp goes to diaphragm and abdominal cavity
• The right diaphragmatic nerve through the hole of the inferior vena cava of diaphragm goes to abdominal plexus and participates in the innervation of the liver.

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• From the diaphragmatic nerves start:
• sensitive pericardial branch (r. pericardiacus), innervating the pericardium and pleura;
• sensitive diaphragmatic-abdominal branches (rr. phrenicoabdominales), innervating the peritoneum of the diaphragm;
• motor branches to the diaphragm.

Clinical anatomy of brachial plexus

Five spinal nerves (C5- Th1) in spatium interscalenum formed trunci plexus brachialis:

truncus superior – formed by connection of anterior branches С5 - С6.

truncus medius — direct continuous of anterior branch С7.

truncus inferior - anterior branches С8 і Th1.

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Trunks of brachial plexus from spatium scaleni exit to great subclavian fossa and formed fasciculus lateralis, fasciculus medialis et fasciculus роsterior

Clinical anatomy of the branches of the supraclavicular part of the brachial plexus

1. n. dorsalis scapulae (C5) innervated -mm. levator scapulae, rhomboidei major et minor.

2. n. thoracicus longus (С6-8) – innervated m. serratus anterior.

3. n. реctorales lateralis ( lateral part) - innervated m. pectoralis minor.

4. n. реctorales medialis ( middle part) — innervated m.pectoralis major.

5. n. suprascapularis (goes to incisura scapule)– innervated mm.supraspinaius et infraspinatus.

6. n.n. subscapulars – innervaited m. teres major

7. n. thoracodorsalis - innervated m. latissimus dorsi

Clinical anatomy of sympatic trunc

Truncus sympathicus on the neck lies anteriorly from the transverse processes of the cervical vertebrae from the base of the skull to the neck of I rib posteriorly or in the thickness of the fascia preveritebralis on the anterior surface of the long muscles of the head and neck.

Ganglion сеrvicale superius

located at the level of bodies II-III of the cervical vertebrae medially to the lower node of the vagus nerve. In front of the upper cervical node is the internal carotid artery and the internal jugular vein.

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The close location of the upper cervical node and the lower node of the vagus nerve at level III of the cervical vertebra allows to perform vagosympathetic blockade according to Vishnevsky.

Х пара

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From the upper cervical node start:

• 1. пп. carotid interni et externi) on the same name vessels formed plexus caroticus internus et externus,
• 2. п. jugularis rise up to the wall of internal jugular vein to the jugular hole and gives branches to n. hypoglossus, ganglion superius et inferius п. Vagi and ganglion inferius n. glossopharyngei.
• 3.n. cardiасus сеrvicalis superior goes near sympatic trunk to the thorax cavity where comes to plexus cardiacus.
• 4.rr. communicantes connect the upper cervical node with the anterior branches of the spinal nerves.
• 5. rr. intergangtionares

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Ganglion сеrvicale medium BRANCHES:

• n. cardiacus сеrvicalis medius goes to the thorax cavity, where comes to plexus cardiacus
• rr. communicantes connect the middle cervical node with the anterior branches С5, С6.
• rr. interganglionares connect the middle cervical node with the upper cervical node and with the ganglion сеrvicothoracicum
• ganglion vertebrale
• located on the anterior surface of the vertebral artery at the level of the transverse processes CVI or CVII.

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Ganglion сеrvicothoracicum (stellatum) is formed at the merger of the lower cervical with the first thoracic node and is located at the level of the transverse process of the VII cervical vertebra in the discharge of the vertebral artery

Branches:

• n. cardiacus сеrvicalis inferior (called, Pavlov’s nerve) on the left passes behind an aorta, on the right - behind a brachiocephalic trunk, then enters a cardiac plexus.
• rr. communicantes connect the cervical-thoracic node with the anterior branches С7_8.
• branches to the subclavian artery, forming a subclavian plexus on it (plexus subclavius).
• п. vertebralis, which forms the spinal plexus on the artery with the same name (plexus vertebralis).

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ganglion сеrvicale superius

ganglion сеrvicale medium

ganglion сеrvicothoracicum (stellatum)]

Vagosympathetic block according to О.V. Vishnevskiy and М.N. Burdenko.�

Vagosympathetic block

• Indications - prevention of pleuropulmonary shock in chest injuries and complex operations on the thoracic cavity.
• The position of the patient on his back, the head is set aside in the opposite direction, the hand on the side of the operation is pulled down.

Technic of vagosympatic block by Vishnevskiy

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1. The index finger of the left hand is set in the middle of the posterior edge of the sternocleidomastoid muscle and when pressed fix it on the transverse process of the vertebra. This technique allows you to divert the vascular-nervous bundle of the neck.

After infiltration of the skin with a solution of novocaine, a needle 10 to 12 cm long is inserted into the tissues with a finger until the bone is felt. As the needle progresses, a solution of novocaine is continuously injected to infiltrate the tissues with an analgesic solution and dilute the blood vessels. After feeling the contact with the spine, the needle is taken back by 1-2 mm. After making sure that no blood enters the syringe, inject 40-50 ml of 0.25% solution of novocaine. The injected solution spreads along the prevertebral fascia and blocks n. vagus and sympathetic nerves.

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After performance of blockade there is a syndrome of Claude - Bernard - Horner �

• redness of the face and eye,
• pupil narrowing (miosis)
• narrowing of the orbit (ptosis)
• drooping eyeball (enophthalmos)

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The body of the sympathetic neuron is located in the lateral horns CVIII – Th I of the spinal cord, axons (preganglionic fibers) go to the neurons of the upper cervical sympathetic node, whose axons (postganglionic fibers), entwining the internal carotid artery, enter the cranial cavity, and then, braiding the ocular artery, reach the orbit and go to the muscle dilating the pupil, the muscle expanding the orbit to the muscles of the orbital tissue, as well as to the walls of the ophthalmic arteries.

Primary surgical treatment of the neck wounds. Features.

PSTW of the neck

Features

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• due to the shift of the layers and organs of the neck, the wound canal may turn into individual cavities or have a tortuous wound course
• the wound channel passes through a lot of cellular spaces of a neck
• wounds of the neck are concluded by injuries of the veins of the neck, which are fixed by the fascia of the neck, due to injuries that may occur air embolism
• neck wounds due to damage of the neck organs (larynx, trachea, esophagus) are often infected.
• Significant frequency of spinal cord and spinal cord injuries

Principles

• Layered expansion of the wound canal along the large muscles and vascular-nervous bundles,
• Removal of non-viable tissue, foreign bodies are removed only in case of danger to large blood vessels, the development of asphyxia
• When the carotid arteries are damaged - access to the vascular-nervous bundle and the imposition of a vascular suture, prosthetics or ligation of the carotid artery
• Expansion and drainage of interfascial cellulose spaces. In the event of phlegmon or abscesses of the neck - their growth and drainage
• When the trachea and larynx are damaged, the cartilage is excised only within the limits where there is no epithelium and the wounds of the organs must be sutured. Often there is a need for tracheal intubation, laryngostomy or tracheostomy. Mandatory for tracheal and laryngeal injuries is drainage of the thoracic anterior mediastinum.
• When the esophagus is injured - the edges of the wound are cut out, a suture is applied to the wall, a rubber probe is inserted through the nasal cavity below the wound to feed the patient. Drainage of the posterior mediastinum.
• Skin sutures are applied only for superficial wounds (up to the second fascia), in all other cases - the wound is not sutured and drainage is installed.