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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4385_Библиотеки_им_академика_М_И_Перельмана
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SURGICAL ANATOMY OF THE NECK
Pr
gland
Ligamentum nuchae Multifidus
d
vical sinus
Clef
ts
1
I
Pouches
1
II
I
II
2
2
3
III
3
IV
44
5
III
Cer
IV
Figure 50.1 Diagram of the branchial apparatus.
Parapharyngeal Space
is inverted pyramid-shaped space extends from the skull base to the hyoid. It is bounded
by the superior constrictor muscle medially and pterygoid muscles, the parotid gland and
the mandible laterally. e styloid process and its attachments divide it into pre-styloid and
post-styloid compartments.
Trapezius
Splenius cervicis
Levator scapulae
Scalenus
medius
Posterior primary
ramus of C6
Longissimus
capitis
Semispinalis
capitis
Semispinalis cervicis
evertebral
fascia
Retropharyngeal
space
Recurrent
laryngeal
nerve
Carotid sheath
and vagus nerve
Internal
jugular vein
Pretracheal
fascia
Thyroid
gland
Infrahyroid
muscles
Parathyroid
Figure 50.2 Fascial layers of the neck.
248 Head and Neck
Investing
layer
Pretracheal
fascia
Platysma
Plane for modified or
Sternocleidomastoid
radical neck dissection
Scalenus
anterior an
phrenic
nerve
Roof of
posterior
triangle
Cervical
sympathetic
External
jugular vein
Level IV lymph node
Table 50.1 Branchial derivatives
Arch Nerve Cartilage Muscle Artery Internal pouch External cleft
1. Mandibular arch Trigeminal
(mandibular
branch V3)
2. Hyoid arch Facial Reichart’s: lesser cornu + upper
Meckel’s cartilage:
mandible; malleus head and neck;
incus body and short process;
hillocks of His 1 (tragus),
2 (helical crus) and 3 (helix)
body of hyoid, long process of
incus, stapes superstructure,
styloid process, hillocks of His
Mylohyoid, anterior
digastric, muscles of
mastication, tensor
tympani, tensor veli
palatini
Muscles of facial
expression, posterior
belly of digastric,
platysma, stapedius
1st aortic arch:
maxillary artery
2nd aortic arch:
stapedial artery
Eustachian tube,
External auditory
middle ear cleft,
medial surface of
tympanic membrane
Palatine tonsil Grows over
4 (antihelix crus), 5 (antitragus,
scapha), 6 (lobule)
3. Glossopharyngeal Greater cornu + lower body of
hyoid
Stylopharyngeus superior
and middle constrictor
3rd aortic arch:
common carotid
Inferior parathyroid
glands, thymic duct
Obliterated
artery
4. Vagus–superior
laryngeal nerve
Thyroid lamina Cricothyroid 4th aortic arch: aorta
on left, subclavian
Superior parathyroid
glands
Obliterated
artery on right
6. Vagus–recurrent
Head and Neck 249
laryngeal nerve
Cricoid, arytenoid cartilages Inferior constrictor,
intrinsic muscles of
larynx
6th aortic arch: ductus
arteriosus and
pulmonary artery
Ultimobrachial body
(forms parafollicular
C cells of thyroid)
Obliterated
meatus, lateral
surface of
tympanic
membrane
remaining
grooves
SURGICAL ANATOMY OF THE NECK
Parotid fascia
paraphar
SURGICAL ANATOMY OF THE NECK
Parapharyngeal
Deep lobe of parotid
Figure 50.3 Parapharyngeal space.
space
extending to
yngeal space
Styloid process
Carotid sheath
Posterior belly
of digastric
Medial pterygoid
muscle
Palatal muscles
Superior
constrictor
Retropharyngeal
space
Retropharyngeal Space
Connecting the two parapharyngeal spaces is the retropharyngeal space. It extends from the
skull base to the level of the carina. e anterior boundary is the buccopharyngeal fascia, the
posterior boundary is the alar fascia.
e ‘danger space’ lies posterior to the retropharyngeal space, between the alar and the prevertebral fascia, extending to the level of the diaphragm.
Cervical Lymphatics
Level I: Level Ia is the single midline zone between the two anterior bellies of digastric
and the hyoid. Ib lies between the anterior and posterior bellies of the digastric muscle
and the mandible.
Level II: Extends from the skull base to the level of the inferior border of the hyoid bone.
e accessory nerve subdivides into IIa and IIb.
Level III: Extends from the level of the inferior border of the hyoid to the inferior aspect
of the cricoid cartilage.
Level IV: is zone extends from the level of the inferior border of the cricoid to the clavicle.
Level V: Extends from a superior apex formed by the junction of the trapezius and ster-
nocleidomastoid muscles to the clavicle inferiorly. e anterior limit is the posterior
border of the sternocleidomastoid and the posterior limit is the anterior border of
trapezius. Subdivided into Va and Vb at the level of the inferior border of the cricoid.
Level VI: Another single midline zone between the common carotid arteries laterally,
from the inferior aspect of the hyoid down to the innominate artery.
Important Nerves
The Facial Nerve
e facial nerve’s main function is motor innervation to the muscles of facial expression. It
also provides motor supply to the posterior belly of digastric and the stylohyoid. e trunk
of the nerve exits the temporal bone via the stylomastoid foramen. It traverses the parotid
250 Head and Neck
SURGICAL ANATOMY OF THE NECK
IIb
Ib
Ia
Figure 50.4 Lymph node zones and subzones.
IIa
III
Va
IV
Vb
gland, dividing into ve main branches. Known as the ‘pes anserinus’, these branches are the
temporal, zygomatic, buccal, marginal mandibular and cervical.
Glossopharyngeal Nerve
e glossopharyngeal nerve exits the skull via the anterior jugular foramen, passing between
the internal jugular vein and the internal carotid artery. It curves around the stylopharyngeus muscle, deep to hyoglossus and enters the constrictor muscles. Fibres are distributed
to the tonsil, pharynx, posterior tongue and minor salivary glands of the oral mucosa and
oropharynx.
Vagus Nerve
e vagus nerve leaves the skull via the middle compartment of the jugular foramen. e
nerve runs posteriorly in the carotid sheath, between the internal jugular vein and common
carotid artery. e vagus nerve gives o the following branches in the neck: auricular branch
(Arnold’s nerve), carotid body branches, pharyngeal branch, superior laryngeal nerve, cardiac branches, and the recurrent laryngeal nerve.
e le recurrent laryngeal nerve leaves the vagus and loops around the ligamentum arteriosum and arch of the aorta before ascending in the tracheo-oesophageal groove. e right
recurrent laryngeal has a more variable path but usually hooks around the subclavian artery
before passing medially toward the tracheo-oesophageal groove. e right nerve is nonrecurrent in 1% of people.
Spinal Accessory Nerve
e nerve exits the skull via the middle compartment of the jugular foramen. It passes deep
to the posterior belly of the digastric, then crosses level II, penetrating the sternocleidomastoid muscle, which it supplies. It usually leaves the posterior aspect of the muscle one centimetre above Erb’s point, where the cervical plexus branches emerge, before running across
Head and Neck 251
SURGICAL ANATOMY OF THE NECK
level V. is is variable and the nerve may not pass through the muscle. e nerve enters the
deep surface of the trapezius at the junction of its lower and middle third.
Hypoglossal Nerve
e hypoglossal nerve provides motor innervation to the intrinsic muscles of the tongue and
all extrinsic muscles except the palatoglossus. It exits the skull via the hypoglossal canal, and
runs deep to the internal jugular vein. It curves around the carotid bifurcation as it heads
anteriorly, passing inferior to the greater horn of the hyoid before coursing superiorly.
Salivary Glands
Parotid Glands
e parotid glands are the largest salivary glands. ey extend from the zygomatic arch
superiorly to the upper part of the neck inferiorly. Medially, they ll the gap between the
mandible and the mastoid. ey extend close to the lateral wall of the oropharynx. e anatomy of the facial nerve is described above. e nerve divides the gland into supercial (80%)
and deep (20%) lobes. e nerve lies supercial to the retromandibular vein. e parotid duct
(of Stensen) originates within the gland; it emerges from the anterior border of the parotid
gland, turning medially at the anterior border of the masseter, before entering the oral cavity
opposite the second upper molar.
Submandibular Glands
ese are the second largest salivary glands. ey lie in the submandibular triangle formed
by the anterior and posterior bellies of the digastric and the margin of the mandible, and
wrap around the posterior border of mylohyoid. e facial artery enters or grooves the gland
posteriorly.
e gland’s brous capsule is crossed by the facial vein, and the marginal mandibular branch
of the facial nerve.
e submandibular duct emerges from the medial surface of the supercial part of the
gland; the lingual nerve begins anteromedial to the duct but crosses underneath to continue
posterolaterally.
Temporal
Branches
Zygomatic
Branches
Buccal Branches
Mandibular
Branches
Figure 50.5 Anatomy of the parotid gland.
252 Head and Neck
Facial Nerve
Parotid
Gland
Cervical Branch
SURGICAL ANATOMY OF THE NECK
12
7
3
6
5
4
Figure 50.6 Submandibular glands. 1. Mandible. 2. Mylohyoid. 3. Anterior belly of digastric. 4.
Submandibular gland. 5. Hyoid. 6. Hypoglossal nerve. 7. Facial artery.
Sublingual Glands
e sublingual glands are the smallest of the named salivary glands and have no true capsule. ey lie beneath the mucosa of the oor of the mouth. ere is no dominant duct drainage; most of the small excretory ducts open directly on the summit of the sublingual fold, but
some may open into the submandibular duct.
The Pharynx
Anatomically, the pharynx is divided into distinctive subdivisions: the nasopharynx, the
oropharynx and the hypopharynx.
e boundaries of the nasopharynx are the two posterior nasal apertures (anteriorly), the
sloping inferior body of the sphenoid bone and the occipital bone (posterosuperiorly), the
so palate (inferiorly) and the superior constrictor muscle (posterolaterally).
e clinical boundaries of the oropharyn x are a horizontal line drawn at the level of the hard
palate (superiorly), a horizontal line drawn through the oor of the valleculae (inferiorly)
and a vertical plane dened by anterior boundary of the palatoglossal folds (anteriorly).
e boundaries of the hypopharynx are the level of the hyoid bone (superiorly) and the lower
margin of the cricoid cartilage (inferiorly). e missing anterior segment corresponds to the
laryngeal inlet.
Pharyngeal Muscles
e pharyngeal muscular wall is relatively thin and comprises three circular constrictor muscles. ey are assisted by three longitudinal muscles, which act as elevators and dilators. e
constrictors sit within each other like three stacked cups and overlap on their posterior aspect.
Head and Neck 253
SURGICAL ANATOMY OF THE NECK
Opening for
ynx
Orophar
La
mandibula
p
yngeus
pharyngotympanic tube
Pharyngeal tonsil
Choana
yngeal
isthmus
Vallecula
ryngeal inlet
Thyroid cartilage
Cricoid cartilage
Figure 50.7 Sagittal section of the head and neck.
Salpingopharyngeus
Palatopharyngeus
Stylo-pharyngeus
Superior
constrictor
Middle
constrictor
Inferior
constrictor
Nasopharynx
Soft palate
Palatine tonsil
Oropharynx
Epiglottis
Hypopharynx/
Laryngophar
Pharyngeal
tubercle
Superior constrictor
Stylo-pharyngeus
Middle constrictor
Inferior constrictor
Pharyngeal raphe
Figure 50.8 Muscles of the pharynx. Left, sagittal section. Middle, lateral view. Right, posterior view.
Pterygo-
r
raphe
Superior
constrictor
Stylohyoid
ligament
Hyoid
bone
Middle
constrictor
Oblique line
of thyroid
cartilage
Inferior constrictor
(has two parts: the to
one is thyrophar
and the bottom one
cricopharyngeus)
Cricoid cartilage
Figure 50.9 Attachments of the constrictor muscles of the pharynx. Left, superior constrictor.
Middle, middle constrictor. Right, inferior constrictor.
254 Head and Neck
SURGICAL ANATOMY OF THE NECK
1 Stylopharyngeus 3 Palatopharyngeus2 Salpingopharyngeus
Figure 50.10 Attachments of the longitudinal muscles of the pharynx. 1, Stylopharyngeus. 2,
Salpingopharyngeus. 3, Palatopharyngeus.
The Larynx
e supraglottis commences at the epiglottis and aryepiglottic folds. Its lower border is a
horizontal line drawn through the apex of the laryngeal ventricle. e glottis extends caudally from this line and includes the vocal cords. e line of demarcation between the glottis
and the subglottis is a line drawn 1cm below the free edge of the vocal fold. e subglottis
becomes the trachea at the lower border of the cricoid.
e framework of the larynx consists of the hyoid bone, and the thyroid, cricoid, epiglottic,
arytenoid, corniculate and cuneiform cartilages.
e intrinsic ligaments of the larynx connect the cartilages together and form an internal
framework. e conus elasticus attaches to the upper border of the cricoid and is stretched
between the inner surface of the thyroid cartilage anteriorly and the vocal process of the
arytenoid behind. e free upper border of this membrane is the vocal ligament.
Muscles of the Larynx
e extrinsic muscles attach the larynx to neighboring structures and maintain the position
of the larynx.
e intrinsic muscles are paired and the majority act to move the arytenoid at the cricoarytenoid joint. e posterior cricoarytenoid is the only abductor of the larynx.
e cricothyroid muscle does not insert into the arytenoid cartilages; it brings the thyroid and cricoid cartilages closer together in a visor-like motion and therefore stretches the
vocal folds.
All the intrinsic muscles of the larynx are supplied by the recurrent laryngeal nerve,
except the cricothyroid, which is supplied by the external branch of the superior laryngeal nerve.
Head and Neck 255
SURGICAL ANATOMY OF THE NECK
T
ytenoid m.
Quadrangular
Hyoepiglottic
T
r
t fibroelastic
membrane)
hyrohyoid
membrane
Muscular
process of
arytenoid
Cricoid
lamina
Cricoid
arch
ligament
Quadrilateral membrane
(upper part fibroelastic
membrane)
Vocal process
of arytenoid
Vestibular fold
and ligament
Thyroepiglottic
ligament
Laryngeal
ventricle
Vocal fold and
ligament
Cricothyroid
ligament
Cricovocal
ligament (lowe
par
Figure 50.11 Sagittal section across the larynx looking laterally.
Hyoid bone
hyroid cartilage
False vocal fold
membrane
Thyroepiglottic m.
Lateral
thyroarytenoid m.
True vocal cord
Vocalis m.
Conus elasticus
Lat. cricoar
Inf. pharyngeal
constrictor m.
Cricothyroid m.
Figure 50.12 Coronal section through the larynx looking anteriorly.
256 Head and Neck
AETIOLOGY OF HEAD AND NECK CANCER
oblique ar
Vocal ligament
Arytenoid cartilage
Cricoid
cartilage
Posterior
cricoarytenoid
muscle
Lateral
cricoarytenoid
muscle
Transverse and
ytenoid
muscles
Cricothyroid
muscles
Thyroarytenoid
muscle
Figure 50.13 Dissected view of the larynx from above.
Muscular process
Vocal process
Thyroid
cartilage
e vocal folds have a supercial squamous epithelium, beneath which is the lamina propria.
is has three distinct layers. e supercial layer is Reinke’s space. e intermediate and deep
layers make up t he vocal ligament. e vocalis muscle lies latera l and deep to the voca l ligament.
51. AETIOLOGY OF HEAD AND NECK CANCER
Introduction
Squamous cell cancer constitutes the most common head and neck malignancy and is related
to tobacco and/or alcohol usage, or infection with human papillomavirus (HPV). Nonsquamous malignancy includes thyroid cancer, salivary gland cancer and sarcomas. ese
malignancies are not associated with tobacco and/or alcohol usage.
Squamous Malignant Tumours
Squamous cell carcinoma of the head and neck encompasses cancer of the oral cavity,
oropharynx, larynx and hypopharynx, nasopharynx, nasal cavity and paranasal sinuses.
Tobacco and Smoking
e main aetiological factors for oral cavity cancer are smoking and alcohol. Tobacco contains over 30 known carcinogens such as polycyclic aromatic hydrocarbons and nitrosamines. ere is a synergistic interaction with alcohol due to the increased mucosal
absorption of these carcinogens due to increased solubility of the carcinogens in alcohol
compared with aqueous saliva. e use of ltered cigarettes reduces this exposure and stopping smoking reduces the risk of head and neck cancer. e risk of oral cancer is reduced
by 50% for those who have discontinued for more than 9 years, but it is unlikely that it
ever returns to the baseline. Pipe and cigar smokers have an increased risk of oral cancer.
Oral cancer is strongly associated with dierent forms of smokeless tobacco consumed by
chewing. ese include bidi, chutta, paan, khaini and toombak. is is particularly common in the Indian subcontinent and accounts for the high incidence of oral cancer in these
Head and Neck 257
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