Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4581_Библиотеки_им_академика_М_И_Перельмана
.pdf
9.2 Auricular Hematoma, “Cauliower Ear”
87
tection, and immune mediators, cartilage is prone
to infection, erosive chondritis, and subsequent
necrosis. It is therefore of great importance, when
repairing injuries to the auricle, to adequately
cover exposed cartilage (Belleza 2006).
When repairing lacerations to the ear, one
aims to appropriately and expediently cover cartilage avoiding wound hematoma (Fig. 9.3) or
abscess formation, but also to restore cosmesis. A
potential hematoma or abscess will prevent
adherence of the nutrient-rich perichondrium to
the auricular cartilage and might result in its
destruction, loss of the skeletal support of the ear,
and eventually abnormal cartilage production,
which leads to the development of a brotic, calcied mass referred to as the “cauliower ear”
(Jones and Mahendran 2004; Ingvaldsen and
Tønseth 2017) or “wrestler’s ear,” because this
type of injury is very common among wrestlers
since early Olympic competition times (Fig.9.4)
(Gifn 1992). Auricular hematoma mοst commonly affects the helical rim or pinna, but sometimes can affect the conchal bowl (Macdonald
etal. 2005). There is no clearly dened best treat-
ment for acute auricular hematoma (Jones and
Mahendran 2004). In the early stages after injury,
simple aspiration is an option (Fig.9.3). However,
reaccumulation occurs, complicating matters,
unless adequate pressure can be maintained with
packing (Gernon 1980). Incision over the most
dependent part of the swelling, raising of skin
aps, drainage of the collection, and scraping of
the undersurface of the aps followed by insertion of a small drain proved to be effective
methods to treat primary as well as recurrent
auricular hematomas (Ghate etal. 2022).
Fig. 9.3 An auricular hematoma of the left ear being
aspirated Fig. 9.4 Example of a “cauliower” or “wrestler’s” ear
88
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Conventional packing materials occasionally
fail. Splinting the pinna by two molds held in
place by light compression bandaging offers a
possible solution in such cases (Macdonald etal.
2005). A more denitive result can be obtained
by incision and drainage. A suction drain is left in
situ or a “button” is sutured over the area in order
to force apposition of the skin, perichondrium,
and cartilage (Bull and Lancer 1984; Tallat etal.
1985). If left untreated, an auricular hematoma
can result in complications such as perichondritis, infection, and necrosis. If treatment is
delayed, a plate of broneocartilage can form
resulting in ear deformity. Surgical excision of
the broneocartilage, done up to 1month following injury, will restore the pinna form. If there is
delay in the excision, a mature cauliower ear
will have formed, and reconstructive plastic surgery is necessary to restore the pinna form
(Yotsuyanagi etal. 2002). The zone and degree of
deformity dene the type of surgical intervention. Cartilage deformity without change in the
outline of the ear can be treated by shaving the
deformed cartilage through a suitable skin incision. For deformities accompanied by a skin decit, a postauricular skin ap should be used
(Yotsuyanagi et al. 2002). Deformities having
caused changes in the outline of the ear require
conchal or costal cartilage grafts, depending on
the structural integrity of the ear, in order to be
restored (Yotsuyanagi etal. 2002).
9.3 Lacerations
Prompt treatment of ear lacerations (Fig. 9.5)
will help avoid functional and aesthetic
complications.
In children, general anesthesia is often
required for more severe lacerations, whereas in
adults, almost every wound can be treated under
local anesthesia, which can be obtained by a great
auricular (a branch of the cervical plexus) and an
auriculotemporal (a branch of V3) nerve block.
Initial wound care of ear lacerations consists of
irrigation. Special attention is paid to fullthickness wounds so that cartilage is not further
dissected from its adherent soft tissues (Fig.9.6).
9 Injuries oftheEars
Fig. 9.5 Patient with lacerations to the right ear
A cotton plug should be inserted into the external
acoustic meatus to prevent the entrance of uid
during irrigation and blood during repair, which
causes discomfort to the patient. Meticulous and
minimal debridement of nonviable tissue is the
next step. Jagged or devitalized cartilage and skin
should be trimmed. Up to 5mm of cartilage can
be removed without risk of evident deformity or
asymmetry of the ear (Brown et al. 2007).
Extensive skin debridement may result in the
need to overstretch the skin and may disrupt the
natural contour of the underlying cartilage and
thus the ear. The rst step in repairing the wound
is the reapproximation of the cartilage. Either
clear Prolene 4.0 or an absorbable 4.0 suture
material is usually used. The initial sutures should
be placed at critical grooves and elds in the cartilage. The stitch through the cartilage should
include the anterior as well as the posterior perichondrium to ensure maximal stability of the
suture. Tearing through the delicate cartilage is
thus avoided and nutrient supply to the damaged
cartilage is provided. Subsequently, the posterior
9.4 Avulsions
Fig. 9.6 Patient with full-thickness laceration of the left
ear (From: The Atlas of Emergency Medicine, 4th Edition,
Knoop KJ, Stack LB, Storrow AB, Thurman RJ (Eds),
McGraw-Hill Education, China, 2016, with permission)
skin, followed by the anterior skin, is repaired.
Interrupted Prolene 5.0 or preferably 6.0 is used
for this purpose. If signicant cartilage and/or
soft-tissue loss precludes an adequate and cosmetically satisfying closure, immediate reconstruction is considered, as will be analyzed in the
following paragraph. In children, the majority of
the wounds can be repaired using steristrips. In a
study of 111 children from Shefeld Children’s
Hospital, 65% of lacerations were treated with
steristrips (Steele and Brennan 2002). Finishing
the repair, the cotton plug is removed from the
external meatus and the meatus is thoroughly
cleaned. Finally, a pressure dressing must be
applied to the ear to prevent postoperative bleeding, hematoma formation, and resulting deformity. Petrolatum jelly-coated gauze should be
placed in the ssures and folds of the ear until the
gauze is level with the helix. The same gauze is
also placed behind the ear. This padding prevents
pain and pressure necrosis caused by the ear
89
pressing against the skull. Another gauze covers
the anterior ear surface. A circumferential head
bandage secures in place the entire assembly. The
dressing is rst changed 2–3 days postoperatively. A lighter dressing can then be applied.
Lacerations to the lobule do not involve cartilage and thus are more easily repaired by simple
suturing or a Z-plasty. Other methods of earlobe
repair have been reviewed by Vujevich et al.
(2007).
9.4 Avulsions
Avulsions can be classied into partial or complete. A partial avulsion or extended laceration
(Steffen et al. 2006) can be then classied
depending on the width of the pedicle (wide or
narrow pedicle) (Lavasani etal. 2010).
Complete avulsions or otherwise traumatic
ear amputations, of a part (Fig.9.7) or of the total
auricular tissue, are rare. Only 74 cases had been
reported in the literature till 2009 (Ihrai et al.
2009). Three-quarters of all patients were
between 11 and 40years of age; the median age
was 28.0 years. There were 56 men and 18
women (male-to-female 3:1). The most frequent
causes were trafc accidents (25/74 cases) and
ghts (21/74 cases). An astonishing one-third of
all injuries resulted from bites, mostly human (17
cases) or dogs (9 cases).
Treatment of these injuries is complex. A good
cosmetic result is the surgeon’s objective; however, demolishing of the auricular area should be
avoided so that future ear reconstruction in case
of replantation failure is possible. The main techniques used for ear replantation are microsurgical
replantation, pocket techniques, and reattachment techniques. Microsurgical replantation
should be the method of choice, whenever this is
possible, because a superior outcome can be
achieved without jeopardizing a subsequent ear
reconstruction with rib cartilage in case of a
failure.
The rst successful microsurgical ear replantation was reported in 1980 (Pennington et al.
1980), and only 25 cases were reported till 2002
(Kind 2002) and 47 until 2013 (Jung etal. 2013).
90
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
ab c
9 Injuries oftheEars
Fig. 9.7 (a and b) Patient with complete avulsion (ampu-
tation) of the lower part of the right auricle and earlobe.
Unfortunately, the avulsed part was lost. The patient opted
It is a lengthy operation; it requires technical
expertise and a lengthy hospital stay, results in
multiple blood transfusions, and has quite a high
failure rate. The main problem is that no suitable
veins can be found; therefore, medicinal leech
therapy is necessary for venous drainage resulting in considerable blood loss. Occasionally, this
leads to a successful outcome (Otto etal. 1999;
Hussey and Kelly 2010), whereas other times
partial or total failure of development of venous
channels leads to ear necrosis when leeching is
stopped (Akyürek etal. 2001; Lin et al. 2010).
Lin et al. (2010) reported on their experience
with six patients who underwent microvascular
ear replantation. In three of them, only arterial
anastomosis was feasible. These patients required
intra-replant heparin injection (chemical leech)
to resolve venous congestion. They all sustained
partial loss of the replanted ear, and secondary
procedures were necessary to repair the
reconstructions.
Steffen etal. (2006) reviewed the trauma cases
of the auricle between 1980 and 2004. Thirtyseven case reports described microsurgical
repairs, mostly used in total amputations. Twothirds (67%) showed a complete recovery. In 14
microsurgical ear replantations, no venous anas-
for primary closure and would consider secondary reconstruction. (c) The patient’s left normal ear
tomosis was performed. In total amputations, the
rate of total recovery without venous anastomosis
was slightly below (ve of eight cases) the rate in
cases with venous anastomosis (13 of 18 cases),
whereas in partial amputations, the reverse was
seen (three of six cases without venous repair
versus one of three cases with) (Steffen et al.
2006).
As already mentioned before, venous conges-
tion is a very regular occurrence in microsurgical
ear replantation. Therefore, most surgeons consider it a characteristic accompanying symptom
rather than a complication (Steffen etal. 2006).
Anemia demanding blood transfusion has been
reported by many authors. Other typical complications for the microsurgical replantation were
arterial spasm, thrombosis of arteries, inammations, hematoma requiring relief, or meatal stenosis (Steffen etal. 2006).
Most microsurgically replanted cases were
amputations of the auricle. However, a few cases
of replantation of the earlobe have also been
reported. Jung etal. (2009) reported the rst successful replantation of an avulsed earlobe by single arterial anastomosis.
When microsurgical replantation is not possi-
ble, one can choose between ear reattachment
9.5 Reconstruction
91
and a pocket technique according to two clinical
features: (1) the size of the amputated part and
(2) the involvement of the earlobe (Ihrai et al.
2009). Ear reattachment is feasible when the
amputated part is smaller than 15 mm or when
amputation involves the earlobe. Pocket techniques, which are appropriate for the replantation
of the auricular cartilage, can be used when the
amputated part is bigger than 15 mm and does
not involve the earlobe (Ihrai etal. 2009).
The reported pocket methods generally dealt
with partial amputations. All pocket reattachments but one were reported to have survived,
and in 67%, complete success was achieved.
Local aps were used in all degrees of trauma.
The classic composite graft method was mainly
used in cases of extended lacerations, with a high
rate of complete intake (Steffen etal. 2006). In
composite graft techniques, several authors noted
the use of heparin or leeches and stitch incisions.
Some surgeons emphasized the importance of
cooling the repaired auricle (Fuleihan et al.
1987).
Despite the fact that the pocket method proved
a success in partial avulsions, it should be remembered that it is a two-stage technique and, in case
of failure, leaves an anatomically altered area.
Especially in complete amputations, indications
for the pocket method should be very carefully
considered. It rarely achieves as good and consistent an aesthetic result as a secondary reconstruction with rib or conchal cartilage, and it almost
always results in a shrunken cartilage and scar
contracture (Steffen etal. 2006).
If a successful revascularization of the amputated auricle seems to be unlikely or if blood
transfusions in the peri- and postoperative course
are denied by the patient, then he/she is best
served with a primary wound closure and the
prospect of a subsequent reconstruction with rib
cartilage (Steffen etal. 2006; Ihrai etal. 2009).
9.5 Reconstruction
Although primary repair is feasible in most cases
of ear trauma, there are instances when delayed
and staged reconstruction is necessary to restore
functional anatomy and aesthetic appearance. It
should be noted that the auricle plays a central
role in facial aesthetics and that auricular deformities can have a signicant impact on psychosocial functioning and self-esteem (Wong et al.
2021).
Understanding the anatomy and recognizing
the circumstances regarding the mechanism of
injury are crucial for successful reconstruction,
though unique and individual structural characteristics should be taken into account (Wong
etal. 2021; Nojoumi and Woo 2021).
A satisfactory primary reconstruction of a
severe auricular trauma is not always possible to
obtain due to either local conditions or failure of
the primary attempt. The resulting defect, which
can produce major psychological distress, ought
to be reconstructed secondarily.
The localization of the defect, its extent, and
the condition of the surrounding tissues are
essential criteria for treatment planning.
Advances in autologous reconstruction using
costal cartilage have resulted in the production of
high-quality auricles, if the procedures are performed in specialist centers with exposure to a
high volume of cases.
For partial ear defects, the two-stage tech-
nique with autologous cartilage previously
described by Brent (1974) and adopted by Nagata
(1993) can be used. In the rst stage, the costal
cartilage of the oating (eight) rib can be utilized
for helical rim defects. For larger defects, a block
of cartilage from the synchondrosis of the sixth
and seventh rib can be harvested. The eighth rib
can serve as a provider of the helical rim if the
block is not of sufcient volume. The rib is
carved into the shape of the missing segment of
the disgured ear, using the uninjured side as a
template. After having been sculpted, the cartilage framework is held together by ne stainless
steel wire. The cartilage construct is attached to
the remaining native ear cartilage and covered
with, usually, a posteriorly based advancement
skin ap. Suction drains are placed under the
construct to allow the overlying skin ap.
Occasionally, a bipedicled skin ap (for middle
helical rim defects) or a postauricular skin ap
(for small upper pole defects) is used (Pearl and
92
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
9 Injuries oftheEars
Sabbagh 2011). The bipedicled skin ap can be
used if there is concern about the blood supply;
however, surgical access is more difcult by this
approach (Pearl and Sabbagh 2011).
In cases of insufcient or poor-quality skin,
preoperative tissue expansion or a temporoparietal fascial ap plus split skin graft is used to
cover the cartilage framework. The latter did not
give a good denition as native or tissueexpanded skin (Pearl and Sabbagh 2011).
In a second stage, 3–6 months later, the ear
construct is released from the side of the head
and the posterior sulcus is created with a split
skin graft. If there is no reasonable projection,
Pearl and Sabbagh (2011) have suggested the use
of a small piece of cartilage behind the construct
covered with either a posterior fascial ap or a
temporoparietal fascial ap covered with a split
skin graft. This provides adequate projection.
Reconstruction of total traumatic defects is
based on the same principles. In such cases, a very
large temporoparietal fascial ap is needed to cover
the cartilage construct (Yamada and Ueda 2012).
Other authors have used a free radial forearm ap
to cover the cartilage and consider it an excellent
choice (Lauwers and van der Hulst 2009).
Simple defects conned to the earlobe can be
reconstructed with conchal cartilage graft, an
anterior skin ap, and a V-Y advancement ap on
the posterior auricular skin (Pearl and Sabbagh
2011). A variety of other, one- or two-stage, pro-
cedures have also been used. The technique
described by Gavello is one of the earliest and
simplest. The bilobed skin ap is designed and
raised, by subcutaneous dissection, at the caudal
end of the ear stump based on the occipital branch
of the posterior auricular artery. Caution not to
injure the latter during ap dissection is essential.
The procedure has several advantages and yields
excellent cosmetic results with preservation of
the earlobe shape and volume. An intact postauricular mastoid region is a sine qua non for the
use of the procedure (Chattopadhyay etal. 2012).
Complications after autologous post- traumatic
ear reconstruction are low. Partial skin necrosis
(4%) and infection (2%) are the commonest.
Conservative management with minimal loss of
denition is feasible in cases of small areas of skin
necrosis. Infection can result in signicant loss of
denition of the construct necessitating further cartilage grafting procedures with additional coastal
cartilage to correct (Pearl and Sabbagh 2011).
Autologous reconstruction is not always wishful or feasible. In such cases, a prosthesis secured
to the remaining ear stump with adhesive (silastic
medical grade adhesive) is a valuable technique.
Silicone elastomers are frequently used for the
fabrication of such auricular prostheses, and the
achieved results are satisfactory (Adeyemo etal.
2008). For virtually complete amputation, osseo-
integrated implants provide a more rigid alternative to adhesive prosthetics. Autologous
reconstruction presents a technical challenge to
the surgeon; however, it is the prosthetic reconstruction which requires lifelong attention and
may be associated with late complications
(Thorne etal. 2001).
References
Adeyemo WL, Jokomba LA, Somefun OA, et al.
Experience with prosthetic reconstruction of ear
defects at LUTH, Lagos, Nigeria. Niger Postgrad Med
J. 2008;15:238–42.
Akyürek M, Safak T, Keҫik A.Microsurgical ear replanta-
tion without venous repair: failure of development of
venous channels despite patency of arterial anastomo-
sis for 14 days. Ann Plast Surg. 2001;46:439–42.
Belleza WG.Otolaryngologic emergencies in the outpa-
tient setting. Med Clin North Am. 2006;90:329–33.
Brent B. Ear reconstruction with an expansible frame-
work of autogenous rib cartilage. Plast Reconstr Surg.
1974;53:619–28.
Brown DJ, Jaffe JE, Henson JK, et al. Advanced lac-
eration management. Emerg Med Clin North Am.
2007;25:83–92.
Bull PD, Lancer JM. Surgeon’s workshop: treatment
of auricular haematomas by suction drainage. Clin
Otorarlyngol Allied Sci. 1984;9:355–60.
Chattopadhyay D, Gupta S, Murmu MB, etal. Revisiting
Gavello’s procedure for single-stage reconstruction of
the earlobe: the vascular basis, technique and clinical
uses. Can J Plast Surg. 2012;20:e22–4.
Fuleihan NS, Natout MAY, Webster RC, etal. Successful
replantation of amputated nose and auricle.
Otolaryngol Head Neck Surg. 1987;97:18–23.
Gernon WH.The care and management of acute hematoma
of the external ear. Laryngoscope. 1980;90:881–5.
Ghate SK, Kalambe A, Maldhure S.Auricular haematoma
an avoidable cosmetic deformity: a chance or negli-
gence. Am J Otolaryngol. 2022;43:103232.
Gifn CS.Wrestler’s ear: pathophysiology and treatment.
Ann Plast Surg. 1992;28:131–9.
References
93
Hussey AJ, Kelly JI.Microsurgical replantation of an ear
with no venous repair. Scand J Plast Reconstr Surg
Hand Surg. 2010;44:64–5.
Ihrai T, Balaquer T, Monteil MC, etal. Surgical manage-
ment of traumatic ear amputations: literature review.
Ann Chir Plast Esthet. 2009;54:146–51.
Ingvaldsen CA, Tønseth KA. Auricular haematoma.
Tidsskr Nor Laegeforen. 2017;137:105–7.
Jones SEM, Mahendran S. Interventions for acute
auricular hematoma. Cochrane Database Syst Rev.
2004;2004(2):CD004166.
Jung SN, Yoon S, Kwon H, etal. Successful replantation
of an amputated earlobe by microvascular anastomosis. J Craniofac Surg. 2009;20:822–4.
Jung SW, Lee J, Oh SJ, etal. A review of microvascular ear
replantation. J Reconstr Microsurg. 2013;29:181–8.
Kind GM. Microvascular ear replantation. Clin Plast
Surg. 2002;29:233–48.
Lauwers T, van der Hulst RR.Microvascular ear recon-
struction using a free radial forearm ap after dog bite.
J Plast Reconstr Aesthet Surg. 2009;62:535–8.
Lavasani L, Leventhal D, Constantinides M, et al.
Management of acute soft tissue injury to the auricle.
Facial Plast Surg. 2010;26:445–50.
Lin PY, Chiang YC, Hsieh SL, etal. Microsurgical replan-
tation and salvage procedures in traumatic ear amputation. J Trauma. 2010;69:E15–9.
Macdonald DJM, Calder N, Perrett G, etal. A novel way
of treating acute cauliower ear in a professional
rugby player. Br J Sports Med. 2005;39:e29.
Nagata S. A new method of total reconstruction of
the auricle for microtia. Plast Reconstr Surg.
1993;92:187–201.
Nojoumi A, Woo BM.Management of ear trauma. Oral
Maxillofac Surg Clin North Am. 2021;33:305–15.
Otto A, Schoeller T, Wechselberger G, et al. Successful
ear replantation without venous anastomosis by
using leeches. Handchir Microchir Plast Chir.
1999;31:98–101.
Pearl RA, Sabbagh W. Reconstruction following trau-
matic partial amputation of the ear. Plast Reconstr
Surg. 2011;127:621–9.
Pennington DG, Lai MF, Pelly AD. Successful replan-
tation of a completely avulsed ear by microvascular
anastomosis. Plast Reconstr Surg. 1980;65:820–3.
Steele BD, Brennan PO.A prospective survey of patients
with presumed accidental ear injury presenting to a
paediatric accident and emergency department. Emerg
Med J. 2002;19:226–8.
Steffen A, Katzbach R, Klaiber S. A comparison of ear
reattachment methods: a review of 25 years since
Pennington. Plast Reconstr Surg. 2006;118:1358–64.
Tallat M, Azab S, Kamel T.Treatment of auricular haema-
toma using button technique. J Otorhinolaryngol Relat
Spec. 1985;47:116–8.
Thorne CH, Brecht LE, Bradley JP, etal. Auricular recon-
struction: indications for autogenous and prosthetic
techniques. Plast Reconstr Surg. 2001;107:1241–52.
Vujevich J, Goldberg LH, Obagi S.Repair of partial and
complete earlobe clefts: a review of 21 methods. J
Drugs Dermatol. 2007;6:695–9.
Wong K, Wong A, Rousso J. Reconstructive options for
auricular trauma. Facial Plast Surg. 2021;37:510–5.
Yamada A, Ueda K.Total auricular reconstruction after
traumatic total amputation of the auricle. J Craniofac
Surg. 2012;23:e241–6.
Yotsuyanagi K, Yamashita K, Urushidate K, etal. Surgical
correction of the cauliower ear. Br J Plast Surg.
2002;55:380–6.
Injuries oftheNeck
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
10
10.1 Anatomy
The neck lies between the head and the trunk providing passage for the many structures communicating between the above two body parts. It
extends from the inferior mandibular margin and
superior nuchal line superiorly to the suprasternal
notch, superior margin of the clavicle, and level
of the seventh cervical vertebra inferiorly.
The neck may be divided into three general
regions, the anterior, the lateral, and the posterior.
The anterior comprises the structures between
the sternocleidomastoid muscles. It is divided by
the hyoid bone into supra- and infrahyoid areas.
The suprahyoid area is further subdivided into
the submental and submaxillary space (Fig.10.1).
The infrahyoid has several subdivisions: supercial infrahyoid, laryngotracheal, thyroid, cervical
esophageal, and prevertebral. The lateral region
is differentiated into the sternocleidomastoid
(carotid) and the supraclavicular areas. The posterior part of the neck is the area lying beneath
the trapezius muscle as far caudally as the rst
rib.
The fasciae of the neck are the supercial and
the deep. The former, carrying the supercial vessels and nerves, is separated from the latter by the
thin platysma muscle (Fig.10.2). The deep fascia
invests and supports the muscles, the pharynx,
the trachea, the esophagus, the lymph nodes, the
large vessels, and the nerves (Anson and McVay
1971). The suprahyoid region is divided into the
median submental and the two lateral submaxillary divisions. The submental area contains the
submental lymph nodes. The submaxillary area
contains the submaxillary (submandibular) salivary gland, the facial artery and vein, the lingual
artery, the lymph nodes, the hypoglossal nerve,
and the lingual nerve.
The supercial infrahyoid region contains the
anterior jugular vein and the infrahyoid muscles.
Spreading aside of the musculoaponeurotic layers of the infrahyoid region reveals the laryngotracheal tube, the thyroid (Fig. 10.3), and the
esophagus in their common fascial casing, the
“visceral sheath” (Anson and McVay 1971).
These structures are designated “the visceral
mass.” This is attached to the vertebral column by
sagittal septa (Anson and McVay 1971).
Important nerves and vessels of the region are the
superior and inferior (recurrent) laryngeal nerve
and the superior and inferior thyroid artery and
vein.
The lateral regions of the neck are the sternomastoid (carotid) and the supraclavicular. The former
comprises the larger area of the lateral region of the
neck. The sternocleidomastoid muscle covers a wide
area of it (Fig.10.1). Upon its surface, the supercial
vessels (external jugular vein) and nerves (greater
auricular nerve) run in duplications of the super-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
C. A. Ioannidis, Soft Tissue Injuries of the Head and Neck,
https://doi.org/10.1007/978-3-031-14915-3_10
95
96
)
muscle fibers
a
Fig. 10.1 Schematic
representation of the
neck regions (and
triangles). The
sternocleidomastoid
muscle (SCM) is clearly
recognizable
10 Injuries oftheNeck
Fig. 10.2 Schematic
representation of the
platysma muscle
SCM
Post cervical
triangle
Accessory
nerve
Omohyoid
(Inf. belly)
Submand
triangle
Carotid
triangle
Omohyoid
(Sup. belly
Platysma
Deep fasci
of the neck
In
Thyroid gland
10.1 Anatomy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
97
cial cervical fascia. The common, internal, and
external carotid artery with all its branches, the
internal jugular vein, and the vagus nerve run deep
to the muscle enclosed in the carotid sheath, a tubular investment of deep cervical fascia (Fig.10.2).
The phrenic, spinal accessory, hypoglossal nerve,
and cervical plexus are important nerve structures
which run at the lateral region of the neck.
The supraclavicular fossa, or posterior cervical triangle, is a depressible space above the middle third of the clavicle, between the posterior
margin of the sternocleidomastoid muscle and
the anterior edge of the trapezius. Although well
protected in the medial portion of its course by
the overlying sternocleidomastoid muscle and
the inner end of the clavicle, the subclavian artery
and vein are liable to injury by penetrating
wounds in the lower neck region (Fig.10.3). The
trunks of the brachial plexus, because of their
proximity to the vessels, may be injured at the
same time (Fig. 10.3). Further cranially lie the
two branches of the subclavian artery in the
supraclavicular fossa, the transverse scapular and
the transverse cervical artery.
The right lymphatic duct drains the lymph from
the right half of the supradiaphragmatic area of the
body. The thoracic duct collects the lymph from the
entire subdiaphragmatic portion of the body as well
as from the left half of the supradiaphragmatic area.
The individual nerves which form the brachial
plexus are the anterior roots of the fth, sixth, seventh, and eighth cervical and rst thoracic spinal
nerves. These roots emerge through the narrow
interval between the anterior and middle scalene
muscles and appear in the lower part of the posterior
triangle of the neck. On the middle scalene muscle,
the anterior roots unite to form trunks (upper, middle, lower trunk). Trauma in the supraclavicular
region may contuse, compress, or lacerate different
portions of the plexus. The subclavian artery and
vein located distally and close to the clavicle usually
escape. Injuries in the region of the scaleni involve
the roots of the plexus. Trauma within the connes
of the supraclavicular fossa involves the trunks.
Fig. 10.3 Schematic
representation of the
great vessels of the neck,
the cervical and brachial
plexuses, and the thyroid
gland
t. carotid artery
Cervical plexus
Int. jugular vein
Brachial plexus
Ext. carotid
artery
Trachea
Соседние файлы в папке Библиотека им академика М.И. Перельмана