Scapular trapezoidal triangle. Triangles of the neck and fascia of the neck. See the meaning of Scapular-trapezoidal Triangle in other dictionaries

Conservative If you have the most “A” answers, then your style is Conservative. Things in subdued colors will suit you - gray, beige, brown, blue, light blue, gray-green, protective, etc. Wear clothes in classic styles, time-tested. Buy

Scapular-trapezoid triangle ( trigonum omotrapezoideum) is limited on the upper inner side by the posterior edge of the sternocleidomastoid muscle ( m. sternocleidomastoideus); from the lower inner side - the lower belly of the omohyoid muscle ( venter inferior m. omohyoidei), behind - the anterior edge of the trapezius muscle ( m. trapezius).

Within the scapulo-trapezoid triangle behind the middle of the sternocleidomastoid muscle, sensory branches of the cervical plexus extend from the inside to the fatty deposits: the greater auricular nerve ( n. auricularis magnus), going up to the area of ​​the outer ear and mastoid process; medial, intermediate and lateral supraclavicular nerves ( nn. supraclaviculares mediales, intermedii et laterales), heading down through the collarbone within the subclavian region; lesser occipital nerve ( n. occipitalis minor), going back and up to the occipital region; transverse cervical nerve ( n. transversus colli), passing in the transverse direction to the midline of the neck (Fig. 7-11 ).

In the scapular-trapezoid triangle the following is produced:

1 ) vagosympathetic blockade;

2 ) anesthesia of the cervical plexus;

3 ) access to the esophagus. The incision is made behind the left sternocleidomastoid muscle, pulling it anteriorly, after which the cervical part of the esophagus is exposed.

4 ) cuts ( incisiones) with deep phlegmon of the neck resulting from injury or perforation of the esophageal wall by a foreign body.

The lower belly of the omohyoid muscle divides the lateral triangle into a larger triangle (trigonum omotrapezoideum) and a smaller triangle (trigonum omoclaviculare). The last triangle corresponds to the large supraclavicular fossa, fossa supraclavicularis major. The skin is thin and mobile. M. platysma covers only the anteroinferior part of the triangle. The subcutaneous tissue contains the middle, intermediate and lateral supraclavicular nerves, nn. supraclaviculares mediales, intermedii et laterales, branches of the cervical plexus innervating the skin of the neck and shoulder girdle. Along the posterior edge of the sternocleidomastoid muscle, the lesser occipital nerve, n. occipitalis minor. Above m. omohyoideus there are two fascia of the neck - proper (II) and prevertebral (V). Below m. omohyoideus behind the second fascia of the neck are the scapuloclavicular (III) fascia of the neck, and behind it is the fifth fascia, which here forms cases for the scalene muscles and is attached with them to the 1st and 2nd ribs, as well as the sheath for the subclavian artery and trunks of the brachial plexus. The accessory nerve passes through the trigonum omotrapezoideum, n. accessorius, innervating the sternocleidomastoid and trapezius muscles. Between the anterior and middle scalene muscles, the cervical and brachial plexuses, plexus cervicalis and plexus brachialis are formed. The trigonum omoclaviculare contains the third section of the subclavian artery and the supraclavicular part of the plexus brachialis. There are three arteries in the scapuloclavicular triangle: a.suprascapularis, a.cervicalis superficialis and a.transversa colli. The lower edge of the artery is covered by the subclavian vein, v.subclavia. In the lateral triangle of the neck there are three groups of lymph nodes: along the accessory nerve, the superficial cervical artery and the supraclavicular group, located along the suprascapular artery. The supraclavicular lymph nodes are connected to the subclavian lymph nodes. Lymph flows here from the tissues of the lateral triangle of the neck, and from the mammary gland, as well as from the organs of the chest cavity.

Operative access to the subclavian artery. Puncture and catheterization of the subclavian vein: indications, technique, complications.

Operative approaches to the subclavian arteries: Access to the artery above the collarbone. When ligating the artery or suturing it above the collarbone, an incision 8-10 cm long is made 1 cm above the collarbone, which reaches the outer edge of the sternocleidomastoid muscle. The tissues are cut layer by layer. It is necessary to strive to manipulate the rib to avoid injury to the dome of the pleura and the thoracic duct. The exposed artery is isolated, a Deschamps needle is placed under it, ligated and dissected between two ligatures. The central segment must be stitched and tied with two ligatures. The wound is sutured.

Access to the artery under the collarbone. When ligating the artery under the clavicle, an incision up to 8 cm long is made parallel to the lower edge of the clavicle and 1 cm below. The tissues are dissected layer by layer. They bluntly penetrate the adipose tissue until they find the inner edge of the pectoralis minor muscle, under which the artery is located. Using a Deschamps needle, strong ligatures are placed, tied, and the artery is cut between them. Subclavian vein starts from the lower border of the 1st rib, goes around it from above, deviates inward, down and slightly forward at the place of attachment to the 1st rib of the anterior scalene muscle and enters the chest cavity. Behind the sternoclavicular joint they connect with the internal jugular vein and form the brachiocephalic vein, which in the mediastinum with the same left side forms the superior vena cava. In front of the PV is the collarbone. The highest point of the PV is anatomically determined at the level of the middle of the clavicle at its upper border.

Laterally from the middle of the clavicle, the vein is located anterior and inferior to the subclavian artery. Medially behind the vein there are bundles of the anterior scalene muscle, the subclavian artery and, then, the dome of the pleura, which rises above the sternal end of the clavicle. The PV passes anterior to the phrenic nerve. On the left, the thoracic lymphatic duct flows into the brachiocephalic vein.

Puncture and catheterization of the subclavian vein:

INDICATIONS for catheterization may be: Inaccessibility of peripheral veins for infusion therapy; long operations with large blood loss; the need for long-term and intensive therapy; the need for parenteral nutrition, including the transfusion of concentrated, hypertonic solutions; the need for diagnostic and control studies (measurement of central venous pressure in the cavities of the heart, X-ray contrast studies, multiple blood samples, etc.).

CONTRAINDICATIONS to PV catheterization are: Severe disturbances of the blood coagulation system towards hypocoagulation; local inflammatory processes at the sites of venous catheterization; severe respiratory failure with pulmonary emphysema; bilateral pneumothorax; injury to the clavicle area. In case of unsuccessful CPV or its impossibility, internal and external jugular or femoral veins are used for catheterization.

Catheterization technique: The room where CPV is performed must be in a sterile operating room: dressing room, intensive care unit or operating room. In preparation for CPV, the patient is placed on the operating table with the head lowered by 15° to prevent air embolism. The head is turned in the direction opposite to the one being punctured, the arms are extended along the body. Under sterile conditions, a table with instruments is set. The doctor washes his hands as before a normal operation and puts on gloves. The surgical field is treated twice with a 2% iodine solution, covered with a sterile diaper and treated again with 70° alcohol. Subclavian access Using a syringe with a thin needle, 0.5% procaine solution is injected intradermally to create a “lemon peel” at a point located 1 cm below the collarbone on the line dividing the middle and inner third of the clavicle. The needle is advanced medially towards the upper edge of the sternoclavicular joint, continuously applying procaine solution. The needle is passed under the collarbone and the rest of the procaine is injected there. The needle is removed. Using a thick sharp needle, limiting the depth of its insertion with the index finger, the skin is pierced to a depth of 1–1.5 cm at the location of the “lemon peel”. The needle is removed. A syringe with a capacity of 20 ml is filled up to half with 0.9% sodium chloride solution, and a not very sharp (to avoid puncture of the artery) needle 7–10 cm long with a bluntly beveled end is put on. The direction of the bevel should be marked on the cannula. When inserting the needle, its bevel should be oriented in the caudal-medial direction. The needle is inserted into a puncture previously made with a sharp needle (see above), and the depth of possible needle insertion should be limited to the index finger (no more than 2 cm). The needle is advanced medially towards the upper edge of the sternoclavicular joint, periodically pulling the plunger back, checking the flow of blood into the syringe. If unsuccessful, the needle is pushed back without removing it completely, and the attempt is repeated, changing the direction of advancement by several degrees. As soon as blood appears in the syringe, part of it is injected back into the vein and again sucked into the syringe, trying to obtain a reliable reverse blood flow. If a positive result is obtained, ask the patient to hold his breath and remove the syringe from the needle, pressing its hole with a finger. A conductor is inserted into the needle with light screwing movements halfway; its length is slightly more than two times the length of the catheter. The patient is again asked to hold his breath, the guide is removed, closing the catheter hole with a finger, then a rubber stopper is put on the latter. After this, the patient is allowed to breathe. If the patient is unconscious, all manipulations associated with depressurization of the lumen of the needle or catheter located in the subclavian vein are performed during exhalation. The catheter is connected to the infusion system and fixed to the skin with a single silk suture. Apply an aseptic dressing.

(trigonum omotrapezoideum) part of the lateral region of the neck, bounded below by the scapulohyoid, behind by the trapezius and in front by the sternocleidomastoid muscles.

View value Scapular-trapezoidal Triangle in other dictionaries

Triangle- and (colloquially) trigon, triangle, m. 1. A geometric figure bounded by three mutually intersecting straight lines, forming three internal angles (mat.). Obtuse.........
Ushakov's Explanatory Dictionary

Trapezoidal Adj.— 1. Looks like a trapezoid.
Explanatory Dictionary by Efremova

Triangle— The model reflected on the technical chart. It has two base points and a top formed by connecting changes in stock prices using a line. In a typical model........
Economic dictionary

Trapezoidal- -th, -oe; -den, -dna, -bottom. Having the shape of a trapezoid (1 sign). T-th detail. T muscles. T thread.
Kuznetsov's Explanatory Dictionary

Triangle- -A; m.
1. A geometric figure bounded by three intersecting lines forming three internal angles. Rectangular, isosceles t. Calculate the area of ​​the triangle.........
Kuznetsov's Explanatory Dictionary

Isosceles triangle— , TRIANGLE having two sides of equal length; The angles at these sides are also equal.

Equilateral triangle- , a flat figure with three sides of equal length; the three internal angles formed by the sides are also equal and amount to 60 °C. see also TRIANGLE.
Scientific and technical encyclopedic dictionary

Spherical Triangle— , A TRIANGLE formed by the intersection on the surface of a SPHERE of the arcs of three large CIRCLES (having the same RADIUS as the sphere). The sides of spherical triangles are measured........
Scientific and technical encyclopedic dictionary

Triangle- (Triangulum), an inconspicuous constellation in the northern hemisphere between the constellations Andromeda and Aries. The brightest star - Beta, 3rd magnitude - forms a distinct triangle........
Scientific and technical encyclopedic dictionary

Triangle Vectors- , a triangle whose sides represent the magnitude and direction of three vectors located in the same plane and forming a closed figure. usually used......
Scientific and technical encyclopedic dictionary

Bermuda Triangle- Atlantic region approx. between the Bermuda Islands, Puerto Rico and the Florida Peninsula, characterized by difficult navigation conditions.

Southern Triangle- (Triangulum Australe), a circumpolar constellation in the southern part of the sky, located south of the constellation Norma. The three brightest stars - Alpha magnitude 1.9, Beta and Gamma (both 2.9) form........
Scientific and technical encyclopedic dictionary

Triangle- a self-sounding musical instrument - a steel rod bent in the shape of a triangle, which is struck with a stick. Used in vorchestras and instrumental ensembles.
Large encyclopedic dictionary

Southern Triangle- (lat. Triangalum Australe) - constellation of the Southern Hemisphere.
Large encyclopedic dictionary

Kionga Triangle- see "Kiong Triangle".

Kiong triangle- conditional name of the territory. between the river Ruvuma and Cape Delgado (from the city of Kionga) in German East Africa, transferred during the division of the former Germans. possessions (after the defeat of Germany........
Soviet historical encyclopedia

Triangle— - a self-sounding musical instrument - a steel rod bent in the shape of a triangle, which is struck with a stick.
Historical Dictionary

Triangle— This geometric term is the name of a musical instrument that is part of the percussion group and is quite often used in symphonic and operatic music. By........
Musical dictionary

Arithmetic Triangle- the same as Pascal's triangle.
Mathematical Encyclopedia

Geodesic Triangle- a figure consisting of three different points and geodesic lines connecting them in pairs. Points called vertices, geodesics - sides. G. t. can be considered......
Mathematical Encyclopedia

Heron Triangle- a triangle whose side lengths and area are expressed in whole numbers. Named after Heron (c. 1st century AD), who examined triangles with sides 13, 14, 15 and 5, 12, 13, areas......
Mathematical Encyclopedia

Triangle- (Italian triangolo, French triangle, German Triangel, English triangle) - a high tessitura percussion instrument. It is a steel rod with a diameter of approx. 8-10 mm; bent in the shape of an isosceles........
Music Encyclopedia

Pascal's Triangle— a table of numbers that are binomial coefficients. In this table, the lateral sides of an isosceles triangle have units, and each of the remaining numbers........
Mathematical Encyclopedia

Triangle- in the Euclidean plane - three points (vertices) and three straight segments (sides) with ends at these points. Sometimes, when defining T., the convex part of the plane is also included in it........
Mathematical Encyclopedia

Scapularly- (scapul-, scapulo-) - a prefix denoting a shoulder blade.
Psychological Encyclopedia

Femoral Triangle- - triangular section of the anterior surface of the thigh, bounded above by the inguinal ligament, externally........
Medical encyclopedia

Bekhterev Scapulohumeral Reflex— (V.M. Bekhterev)
see Scapulohumeral reflex.
Medical encyclopedia

Bochdaleka Triangle— (V.A. Bochdalek)
see Lumbocostal triangle (Lumbocostal triangle).
Medical encyclopedia

Bryant's Triangle- (Th. Bryant; syn. Brion triangle - nrk)
a triangle, the sides of which are the continuation of the axis of the femur, a perpendicular lowered onto it from the anterior superior iliac spine.........
Medical encyclopedia

Briona Triangle- (nrk; T. Bryant, 1828-1914, English surgeon)
see Bryant triangle.
Medical encyclopedia

The structure of the neck of each person implies the presence of four areas: posterior, anterior, lateral, sternocleidomastoid. The triangles of the neck are located within these areas, and during surgery they are the main guides.

Every person's neck has a midline that starts at the chin and ends at the jugular notch. Thus, this line divides the neck into two equal parts - the right side and the left side, which, in turn, are divided into two triangles:

• front;
• rear.

The anterior cervical triangle is located in the anterior part. It has certain restrictions - the lower jaw, the anterior edge and the midline. The upper abdomen divides this triangle into several smaller ones:

News line ✆

• sleepy;
• scapular-tracheal;
• submandibular;
• Pirogov triangle;
• scapuloclavicular;
• extramandibular fossa.

Classification

Sleepy. This section contains the internal and external carotid arteries, the vagus nerve, and the internal jugular vein. During surgery on the carotid artery, it is ligated to prevent bleeding.

Scapular-tracheal. In this area there are organs that are especially important for humans, such as the trachea, larynx, carotid artery, and thyroid gland. The following surgical interventions are performed in this area:

• strumectomy;
• tracheotomy;
• ligation of the carotid artery;
• laryngectomy.

Submandibular. In this area there are two nerves, the hypoglossal and lingual, and an artery. This triangle is used for surgical interventions for the following diseases:

• in case of a malignant tumor of the lip or tongue, complete removal of the lymph nodes is performed;
• when tumors appear, the submandibular salivary glands are removed;
• An incision is made in the floor of the mouth in the presence of phlegmon.

Pirogov's triangle. This area is located in the submandibular triangle. In order for the doctor to get to the lingual artery during surgery, he first needs to cut the fibers of the hyoid-lingual muscle, which is located obliquely - longitudinally.

The posterior cervical triangle is located in the middle of the collarbone and between the trapezius muscle. It, in turn, is divided into smaller triangles of the neck.

Scapuloclavicular. The jugular and suprascapular vein and artery pass through this area. During surgical intervention in this area, the subclavian vein and artery are ligated, and in the upper extremities, brachial plexus anesthesia is performed.

Scapular-trapezoidal. In this area, under the collarbone, there passes an artery, a vein, an accessory nerve, and two cervical arteries: the transverse and superficial.

Extramandibular fossa. This area has the auriculotemporal nerve, the maxillary vein, the external carotid artery, and the facial nerve. Also between the scalene muscles there are two spaces in the form of a triangular shape: prescalene and interscalene.

Classification of cervical fascia

The fascia of the neck is located in the cervical region and reflects the topography of the organs. Each fascia of the neck is a kind of connective tissue framework, which is located throughout its entire area and unites them. Each fascia of the neck has a different origin, some were formed as a result of reduced muscles, and others as a result of compaction of the tissue that surrounds all the cervical organs. As a result, they have a variety of thickness, density and length. Each author classifies them differently, so below are the fascia of the neck according to V. M. Shevkunenko.

Superficial. By its nature it is thin and loose. It spreads from the cervical area to the face, as well as the human chest.

Own. It is strengthened in several places, one part of it to the collarbone and sternum, and the second to the lower jaw. In the posterior part of the fascia of the neck, they are attached to the processes of the cervical vertebrae.

Deep and superficial layers of the cervical fascia. It resembles the shape of a trapezoid and forms a special space for the muscles, and in front the fascial sheet covers the larynx, trachea, and thyroid gland. The second and third fascial layers merge into one along the midline, thus forming the linea alba.

The superficial leaf forms a kind of collar on the neck, which completely envelops the nerves and blood vessels of a person. These two layers of neck fascia form a slit-like space. This space contains veins, as well as loose tissue; damage to them is very dangerous for human health.

Intracervical. Surrounds such important organs as the trachea, pharynx, larynx, thyroid gland, esophagus.

Prevertebral. It is located on the human spine, enveloping the long muscles of the head. It starts from the back of the skull and goes down through the entire throat.

All of the neck fascia provided are varied, some are reduced muscles, other neck fascia are a product of fiber compaction, and the third are of natural origin.

Thus, each triangle and fascia in human anatomy plays a specific and very important role. All of them are of different sizes and have their own specific, responsible function in human anatomy, and during surgical intervention they are landmarks. All fascia of the neck have a strong connection with the walls of the veins, which perfectly promotes venous outflow.

12.1. BORDERS, AREAS AND NECK TRIANGLES

The boundaries of the neck area are from above a line drawn from the chin along the lower edge of the mandible through the apex of the mastoid process along the superior nuchal line to the external occipital protuberance, from below - a line from the jugular notch of the sternum along the upper edge of the clavicle to the acromiocleidoclavicular joint and further to the spinous process of the VII cervical vertebra.

The sagittal plane, drawn through the midline of the neck and the spinous processes of the cervical vertebrae, divides the neck region into the right and left halves, and the frontal plane, drawn through the transverse processes of the vertebrae, into the anterior and posterior regions.

Each anterior region of the neck is divided into internal (medial) and external (lateral) triangles by the sternocleidomastoid muscle (Fig. 12.1).

The boundaries of the medial triangle are the lower edge of the mandible above, the anterior edge of the sternocleidomastoid muscle behind, and the midline of the neck in front. Within the medial triangle are the internal organs of the neck (larynx, trachea, pharynx, esophagus, thyroid and parathyroid glands) and there are a number of smaller triangles: submental triangle (trigonum submentale), submandibular triangle (trigonum submandibulare), carotid triangle (trigonum caroticum), scapular-tracheal triangle (trigonum omotracheale).

The boundaries of the lateral triangle of the neck are below the clavicle, medially - the posterior edge of the sternocleidomastoid muscle, behind - the edge of the trapezius muscle. The inferior belly of the omohyoid muscle divides it into the scapuloclavicular and scapuloclavicular triangles.

Rice. 12.1.Neck triangles:

1 - submandibular; 2 - sleepy; 3 - scapular-tracheal; 4 - scapular-trapezoidal; 5 - scapuloclavicular

12.2. FASCIA AND CELLULAR SPACES OF THE NECK

12.2.1. Fascia of the neck

According to the classification proposed by V.N. Shevkunenko, there are 5 fascia on the neck (Fig. 12.2):

Superficial fascia of the neck (fascia superficialis colli);

Superficial layer of the fascia propria of the neck (lamina superficialis fasciae colli propriae);

Deep layer of the cervical fascia (lamina profunda fascae colli propriae);

Intracervical fascia (fascia endocervicalis), consisting of two layers - parietal (4 a - lamina parietalis) and visceral (lamina visceralis);

prevertebral fascia (fascia prevertebralis).

According to the International Anatomical Nomenclature, the second and third fascia of the neck are respectively called proper (fascia colli propria) and scapular-clavicular (fascia omoclavicularis).

The first fascia of the neck covers both its posterior and anterior surfaces, forming a sheath for the subcutaneous muscle of the neck (m. platysma). At the top it goes to the face, and at the bottom to the chest area.

The second fascia of the neck is attached to the anterior surface of the manubrium of the sternum and clavicles, and at the top - to the edge of the lower jaw. It gives spurs to the transverse processes of the vertebrae, and is attached posteriorly to their spinous processes. This fascia forms cases for the sternocleidomastoid (m. sternocleidomastoideus) and trapezius (m. trapezius) muscles, as well as for the submandibular salivary gland. The superficial layer of fascia, running from the hyoid bone to the outer surface of the lower jaw, is dense and durable. The deep leaf reaches significant strength only at the boundaries of the submandibular bed: at the site of its attachment to the hyoid bone, to the internal oblique line of the lower jaw, with the formation of the cases of the posterior belly of the digastric muscle and the stylohyoid muscle. In the area of ​​the maxillary-hyoid and hyoid-lingual muscles, it is loosened and weakly expressed.

In the submental triangle, this fascia forms cases for the anterior bellies of the digastric muscles. Along the midline formed by the suture of the mylohyoid muscle, the superficial and deep leaves are fused to each other.

The third fascia of the neck starts from the hyoid bone, goes down, having the outer border of the scapular-hyoid muscle (m.omohyoideus), and below it is attached to the posterior surface of the manubrium of the sternum and clavicles. It forms fascial sheaths for the sternohyoid (m. sternohyoideus), scapular-hyoid (m. omohyoideus), sternothyroid (m. sternothyrcoideus) and thyrohyoid (m. thyreohyoideus) muscles.

The second and third fascia along the midline of the neck grow together in the space between the hyoid bone and a point located 3-3.5 cm above the manubrium of the sternum. This formation is called the white line of the neck. Below this point, the second and third fascia diverge to form the suprasternal interaponeurotic space.

The fourth fascia at the top is attached to the outer base of the skull. It consists of parietal and visceral layers. Visceral

the leaf forms cases for all organs of the neck (pharynx, esophagus, larynx, trachea, thyroid and parathyroid glands). It is equally well developed in both children and adults.

The parietal layer of fascia is connected with the prevertebral fascia by strong spurs. The pharyngeal-vertebral fascial spurs divide all the fiber around the pharynx and esophagus into retropharyngeal and lateral pharyngeal (peripharyngeal) fiber. The latter, in turn, is divided into anterior and posterior sections, the border between which is the stylopharyngeal aponeurosis. The anterior section is the bottom of the submandibular triangle and descends to the hyoid muscle. The posterior section contains the common carotid artery, internal jugular vein, the last 4 pairs of cranial nerves (IX, X, XI, XII), deep cervical lymph nodes.

Of practical importance is the fascia spur that runs from the posterior wall of the pharynx to the prevertebral fascia from the base of the skull to the III-IV cervical vertebrae and divides the retropharyngeal space into the right and left halves. From the boundaries of the posterior and lateral walls of the pharynx, spurs (Charpy's ligaments) stretch to the prevertebral fascia, separating the retropharyngeal space from the posterior part of the peripharyngeal space.

The visceral layer forms fibrous cases for organs and glands located in the area of ​​the medial triangles of the neck - the pharynx, esophagus, larynx, trachea, thyroid and parathyroid glands.

The fifth fascia is located on the muscles of the spine, forms closed cases for the long muscles of the head and neck and passes to the muscles starting from the transverse processes of the cervical vertebrae.

The outer part of the prevertebral fascia consists of several spurs that form cases for the levator scapulae muscle and the scalene muscles. These cases are closed and go to the scapula and ribs I-II. Between the spurs there are cellular fissures (prescalene and interscalene spaces), where the subclavian artery and vein, as well as the brachial plexus, pass.

Fascia takes part in the formation of the fascial sheath of the brachial plexus and the subclavian neurovascular bundle. The cervical part of the sympathetic trunk is located in the split of the prevertebral fascia. The vertebral, inferior thyroid, deep and ascending cervical vessels, as well as the phrenic nerve pass through the thickness of the prevertebral fascia.

Rice. 12.2.Topography of the neck on a horizontal cut:

1 - superficial fascia of the neck; 2 - superficial leaf of the neck’s own fascia; 3 - deep leaf of the neck's own fascia; 4 - parietal leaf of the intracervical fascia; 5 - visceral leaf of the intracervical fascia; 6 - capsule of the thyroid gland; 7 - thyroid gland; 8 - trachea; 9 - esophagus; 10 - neurovascular bundle of the medial triangle of the neck; 11 - retrovisceral cellular space; 12 - prevertebral fascia; 13 - spurs of the second fascia of the neck; 14 - superficial muscle of the neck; 15 - sternohyoid and sternothyroid muscles; 16 - sternocleidomastoid muscle; 17 - omohyoid muscle; 18 - internal jugular vein; 19 - common carotid artery; 20 - vagus nerve; 21 - borderline sympathetic trunk; 22 - scalene muscles; 23 - trapezius muscle

12.2.2. Cellular spaces

The most important and well-defined is the cellular space surrounding the insides of the neck. In the lateral sections, the fascial sheaths of the neurovascular bundles are adjacent to it. The tissue surrounding the organs in the front looks like pronounced adipose tissue, and in the posterolateral sections it looks like loose connective tissue.

In front of the larynx and trachea there is a pretracheal cellular space, limited from above by the fusion of the third fascia of the neck (deep layer of the own fascia of the neck) with the hyoid bone, from the sides - by its fusion with the fascial sheaths of the neurovascular bundles of the medial triangle of the neck, from behind - by the trachea, down to 7-8 tracheal rings. On the anterior surface of the larynx this tissue space is not expressed, but downward from the isthmus of the thyroid gland there is fatty tissue containing vessels [the lowest thyroid artery and veins (a. et vv. thyroideae imae)]. The pretracheal space in the lateral sections extends to the outer surface of the thyroid lobes. Below, the pretracheal space along the lymphatic vessels connects with the tissue of the anterior mediastinum.

The pretracheal tissue passes posteriorly into the lateral paraesophageal space, which is a continuation of the parapharyngeal space of the head. The peri-esophageal space is limited externally by the sheaths of the neurovascular bundles of the neck, and posteriorly by lateral fascial spurs running from the visceral layer of the intracervical fascia, which forms the fibrous sheath of the esophagus, to the sheaths of the neurovascular bundles.

The posterior esophageal (retrovisceral) cellular space is limited in front by the visceral layer of the intracervical fascia on the posterior wall of the esophagus, and in the lateral sections by the pharyngeal-vertebral spurs. These spurs delimit the paraesophageal and retroesophageal spaces. The latter passes at the top into the retropharyngeal tissue, divided into right and left halves by a fascial layer running from the posterior wall of the pharynx to the spine in the sagittal plane. It does not go down below the VI-VII cervical vertebrae.

Between the second and third fascia, directly above the manubrium of the sternum, there is a suprasternal interfascial cellular space (spatium interaponeuroticum suprasternale). Its vertical size is 4-5 cm. To the sides of the midline it is

the space communicates with Gruber's bags - cellular spaces located behind the lower sections of the sternocleidomastoid muscles. At the top they are delimited by the fusions of the second and third fascia of the neck (at the level of the intermediate tendons of the omohyoid muscles), at the bottom by the edge of the sternal notch and the upper surface of the sternoclavicular joints, from the outside they reach the lateral edge of the sternocleidomastoid muscles.

The fascial sheaths of the sternocleidomastoid muscles are formed by the superficial layer of the own fascia of the neck. At the bottom they reach the attachment of the muscle to the clavicle, sternum and their articulation, and at the top - to the lower border of the formation of the muscle tendon, where they fuse with them. These cases are closed. The layers of adipose tissue are more pronounced on the back and inner surfaces of the muscles, and to a lesser extent on the front.

The anterior wall of the fascial sheaths of the neurovascular bundles, depending on the level, is formed either by the third (below the intersection of the sternocleidomastoid and omohyoid muscles) or the parietal layer of the fourth (above this intersection) fascia of the neck. The posterior wall is formed by a spur of the prevertebral fascia. Each element of the neurovascular bundle has its own sheath, so the common neurovascular sheath consists of three in total - the sheath of the common carotid artery, the internal jugular vein and the vagus nerve. At the level of the intersection of the vessels and nerve with the muscles coming from the styloid process, they are tightly fixed to the posterior wall of the fascial sheaths of these muscles, and, thus, the lower part of the sheath of the neurovascular bundle is delimited from the posterior part of the peripharyngeal space.

The prevertebral space is located behind the organs and retropharyngeal tissue. It is delimited by the common prevertebral fascia. Inside this space there are fiber gaps in the fascial sheaths of individual muscles lying on the spine. These gaps are delimited from each other by the attachment of sheaths along with long muscles on the vertebral bodies (below, these spaces reach the II-III thoracic vertebrae).

The fascial sheaths of the scalene muscles and trunks of the brachial plexus are located outward from the bodies of the cervical vertebrae. The trunks of the plexus are located between the anterior and middle scalene muscles. Interscalene space along the branches of the subclavian

The artery connects with the prevertebral space (along the vertebral artery), with the pretracheal space (along the inferior thyroid artery), with the fascial sheath of the fatty lump of the neck between the second and fifth fascia in the scapular-trapezoid triangle (along the transverse artery of the neck).

The fascial sheath of the neck fat pad is formed by the superficial layer of the fascia propria of the neck (in front) and the prevertebral fascia (back) between the sternocleidomastoid and trapezius muscles in the scapulo-trapezoid triangle. The fatty tissue of this case descends into the scapuloclavicular triangle, located under the deep layer of the fascia of the neck.

Messages from the cellular spaces of the neck. The cellular spaces of the submandibular region have direct communication with both the submucosal tissue of the floor of the mouth and the fatty tissue filling the anterior peripharyngeal cellular space.

The retropharyngeal space of the head directly passes into the tissue located behind the esophagus. At the same time, these two spaces are separated from other cellular spaces of the head and neck.

The fatty tissue of the neurovascular bundle is well demarcated from adjacent cellular spaces. It is extremely rare to observe the spread of inflammatory processes to the posterior part of the peripharyngeal space along the internal carotid artery and internal jugular vein. There is also rarely a connection between this space and the anterior part of the peripharyngeal space. This may occur due to insufficient development of the fascia between the stylohyoid and stylohyoid muscles. Downward, the fiber extends to the level of the venous angle (Pirogov) and the place where its branches depart from the aortic arch.

The peri-esophageal space in most cases communicates with the fiber located on the anterior surface of the cricoid cartilage and the lateral surface of the larynx.

The pretracheal space sometimes communicates with the peri-esophageal spaces, much less often with the anterior mediastinal tissue.

The suprasternal interfascial space with Gruber's bags are also isolated.

The fiber of the lateral triangle of the neck has communications along the trunks of the brachial plexus and branches of the subclavian artery.

12.3. FRONT NECK AREA

12.3.1. Submandibular triangle

The submandibular triangle (trigonum submandibulare) (Fig. 12.4) is limited by the anterior and posterior bellies of the digastric muscle and the edge of the lower jaw, which forms the base of the triangle at the top.

Leathermobile and easily extensible.

The first fascia forms the sheath of the subcutaneous muscle of the neck (m. p1atysma), the fibers of which are directed from bottom to top and from outside to inside. The muscle starts from the pectoral fascia below the collarbone and ends on the face, partly connecting with the fibers of the facial muscles in the area of ​​the corner of the mouth, partly intertwining with the parotid-masticatory fascia. The muscle is innervated by the cervical branch of the facial nerve (r. colli n. facialis).

Between the posterior wall of the sheath of the subcutaneous muscle of the neck and the second fascia of the neck immediately below the edge of the lower jaw lies one or more superficial submandibular lymph nodes. In the same layer pass the upper branches of the transverse nerve of the neck (n. transversus colli) from the cervical plexus (Fig. 12.3).

Under the second fascia in the area of ​​the submandibular triangle are the submandibular gland, muscles, lymph nodes, vessels and nerves.

The second fascia forms the capsule of the submandibular gland. The second fascia has two leaves. The superficial one, covering the outer surface of the gland, is attached to the lower edge of the lower jaw. Between the angle of the lower jaw and the anterior edge of the sternocleidomastial muscle, the fascia thickens, extending deep into a dense septum that separates the bed of the submandibular gland from the bed of the parotid gland. Directing towards the midline, the fascia covers the anterior belly of the digastric muscle and the mylohyoid muscle. The submandibular gland is partially adjacent directly to the bone, the inner surface of the gland is adjacent to the maxillary-hyoid and hyoid-lingual muscles, separated from them by a deep layer of the second fascia, which is significantly inferior in density to the surface layer. Below, the gland capsule is connected to the hyoid bone.

The capsule surrounds the gland freely, without merging with it and without sending processes into the depths of the gland. Between the submandibular gland and its capsule there is a layer of loose fiber. The gland bed is closed from all

sides, especially at the level of the hyoid bone, where the superficial and deep layers of its capsule grow together. Only in the anterior direction does the fiber contained in the gland bed communicate along the gland duct in the gap between the mylohyoid and hyoid muscles with the fiber of the floor of the mouth.

The submandibular gland fills the space between the anterior and posterior bellies of the digastric muscle; it either does not go beyond the boundaries of the triangle, which is typical of old age, or it is large in size and then goes beyond its limits, which is observed at a young age. In older people, the submandibular gland is sometimes well contoured due to partial atrophy of the subcutaneous tissue and subcutaneous muscle of the neck.

Rice. 12.3.Superficial nerves of the neck:

1 - cervical branch of the facial nerve; 2 - greater occipital nerve; 3 - lesser occipital nerve; 4 - posterior auricular nerve; 5 - transverse nerve of the neck; 6 - anterior supraclavicular nerve; 7 - middle supraclavicular nerve; 8 - posterior supraclavicular nerve

The submandibular gland has two processes extending beyond the gland bed. The posterior process goes under the edge of the lower jaw and reaches the place of attachment of the internal pterygoid muscle to it. The anterior process accompanies the excretory duct of the gland and, together with it, passes into the gap between the mylohyoid and mylohyoid muscles, often reaching the sublingual salivary gland. The latter lies under the mucous membrane of the floor of the mouth on the upper surface of the mylohyoid muscle.

Around the gland lie the submandibular lymph nodes, adjacent mainly to the upper and posterior edges of the gland, where the anterior facial vein passes. Often the presence of lymph nodes is noted in the thickness of the gland, as well as between the leaves of the fascial septum separating the posterior end of the submandibular gland from the lower end of the parotid gland. The presence of lymph nodes in the thickness of the submandibular gland makes it necessary to remove not only the submandibular lymph nodes, but also the submandibular salivary gland (if necessary, on both sides) in case of metastases of cancerous tumors (for example, the lower lip).

The excretory duct of the gland (ductus submandibularis) starts from the inner surface of the gland and stretches anteriorly and upward, penetrating the gap between m. hyoglossus and m. mylohyoideus and then passing under the mucous membrane of the floor of the mouth. This intermuscular gap, which allows the passage of a salivary duct surrounded by loose tissue, can serve as a path through which pus from phlegmon of the floor of the mouth descends into the area of ​​the submandibular triangle. Below the duct, the hypoglossal nerve (n. hypoglossus) penetrates into the same gap, accompanied by the lingual vein (v. lingualis), and above the duct it goes, accompanied by the lingual nerve (n. lingualis).

Deeper than the submandibular gland and the deep plate of the second fascia are muscles, vessels and nerves.

Within the submandibular triangle, the superficial layer of muscles consists of the digastric (m. digastricum), stylohyoid (m. stylohyoideus), mylohyoid (m.mylohyoideus) and hypoglossal (m. hyoglossus) muscles. The first two limit (with the edge of the lower jaw) the submandibular triangle, the other two form its bottom. The posterior belly of the digastric muscle begins from the mastoid notch of the temporal bone, the anterior one - from the same-named fossa of the lower jaw, and the tendon connecting both bellies is attached to the body of the hyoid bone. To the rear abdomen

The digastric muscle is adjacent to the stylohyoid muscle, starting from the styloid process and attached to the body of the hyoid bone, while covering the tendon of the digastric muscle with its legs. The mylohyoid muscle lies deeper than the anterior belly of the digastric muscle; it starts from the line of the same name of the lower jaw and is attached to the body of the hyoid bone. The right and left muscles converge along the midline, forming a suture (raphe). Both muscles form an almost quadrangular plate, forming the so-called diaphragm of the mouth.

The mylohyoid muscle is a continuation of the mylohyoid muscle. However, the other end of the mylohyoid muscle is connected to the lower jaw, while the mylohyoid muscle goes to the lateral surface of the tongue. The lingual vein, hypoglossal nerve, duct of the submandibular salivary gland and lingual nerve pass along the outer surface of the hyoglossus muscle.

The facial artery always passes in the fascial bed under the edge of the mandible. In the submandibular triangle, the facial artery makes a bend, passing along the upper and posterior surfaces of the posterior pole of the submandibular gland near the wall of the pharynx. The facial vein passes through the thickness of the superficial plate of the second fascia of the neck. At the posterior border of the submandibular triangle, it merges with the retromandibular vein (v. retromandibularis) into the common facial vein (v. facialis communis).

In the space between the mylohyoid and mylohyoid muscles, the lingual nerve passes, giving off branches to the submandibular salivary gland.

A small area of ​​the triangle area where the lingual artery may be exposed is called Pirogov's triangle. Its boundaries are: upper - the hypoglossal nerve, lower - the intermediate tendon of the digastric muscle, anterior - the free edge of the mylohyoid muscle. The bottom of the triangle is the hyoid muscle, the fibers of which must be separated to expose the artery. Pirogov's triangle is detected only if the head is thrown back and strongly turned in the opposite direction, and the gland is removed from its bed and pulled upward.

Submandibular lymph nodes (nodi lymphatici submandibulares) are located on top, in the thickness or under the superficial plate of the second fascia of the neck. Lymph flows into them from the medial

Rice. 12.4.Topography of the submandibular triangle of the neck: 1 - proper fascia; 2 - angle of the lower jaw; 3 - posterior belly of the digastric muscle; 4 - anterior belly of the digastric muscle; 5 - hypoglossus muscle; 6 - mylohyoid muscle; 7 - Pirogov triangle; 8 - submandibular gland; 9 - submandibular lymph nodes; 10 - external carotid artery; 11 - lingual artery; 12 - lingual vein; 13 - hypoglossal nerve; 14 - common facial vein; 15 - internal jugular vein; 16 - facial artery; 17 - facial vein; 18 - mandibular vein

parts of the eyelids, external nose, mucous membrane of the cheek, gums, lips, floor of the mouth and middle part of the tongue. Thus, during inflammatory processes in the area of ​​the inner part of the lower eyelid, the submandibular lymph nodes enlarge.

12.3.2. Sleepy triangle

The carotid triangle (trigonum caroticum) (Fig. 12.5) is limited laterally by the anterior edge of the sternocleidomastoid muscle, from above by the posterior belly of the digastric muscle and stylohyoid muscle, from the inside by the superior belly of the omohyoid muscle.

Leatherthin, flexible, easy to fold.

Innervation is carried out by the transverse nerve of the neck (n. transverses colli) from the cervical plexus.

The superficial fascia contains fibers of the subcutaneous muscle of the neck.

Between the first and second fascia is the transverse nerve of the neck (n. transversus colli) from the cervical plexus. One of its branches goes to the body of the hyoid bone.

The superficial layer of the own fascia of the neck under the sternocleidomastoid muscle fuses with the sheath of the neurovascular bundle formed by the parietal layer of the fourth fascia of the neck.

In the vagina of the neurovascular bundle, the internal jugular vein is located laterally, the common carotid artery (a. carotis communis) is located medially, and the vagus nerve (n.vagus) is located behind them. Each element of the neurovascular bundle has its own fibrous sheath.

The common facial vein (v. facialis communis) flows into the vein from above and medially at an acute angle. A large lymph node may be located in the corner at the site of their confluence. Along the vein in her vagina is a chain of deep lymph nodes in the neck.

On the surface of the common carotid artery, the upper root of the cervical loop descends from top to bottom and medially.

At the level of the upper edge of the thyroid cartilage, the common carotid artery is divided into external and internal. The external carotid artery (a.carotis externa) is usually located more superficially and medially, and the internal carotid artery is located more laterally and deeper. This is one of the signs that the vessels differ from each other. Another distinctive feature is the presence of branches in the external carotid artery and their absence in the internal carotid artery. In the area of ​​bifurcation there is a slight expansion that continues onto the internal carotid artery - the carotid sinus (sinus caroticus).

On the posterior (sometimes on the medial) surface of the internal carotid artery there is a carotid tangle (glomus caroticum). In the fatty tissue surrounding the carotid sinus and carotid glomerulus lies a nerve plexus formed by the branches of the glossopharyngeal, vagus nerves and the borderline sympathetic trunk. This is a reflexogenic zone containing baro- and chemoreceptors that regulate blood circulation and breathing through the Hering nerve together with the Ludwig-Zion nerve.

The external carotid artery is located in the angle formed by the trunk of the common facial vein from the inside, the internal jugular vein laterally, and the hypoglossal nerve from above (Farabeuf's triangle).

At the site of formation of the external carotid artery is the superior thyroid artery (a.thyroidea superior), running medially and downward, going under the edge of the upper belly of the omohyoid muscle. At the level of the upper edge of the thyroid cartilage, the superior laryngeal artery departs from this artery in the transverse direction.

Rice. 12.5.Topography of the carotid triangle of the neck:

1 - posterior belly of the digastric muscle; 2 - upper belly of the omohyoid muscle; 3 - sternocleidomastoid muscle; 4 - thyroid gland; 5 - internal jugular vein; 6 - facial vein; 7 - lingual vein; 8 - superior thyroid vein; 9 - common carotid artery; 10 - external carotid artery; 11 - superior thyroid artery; 12 - lingual artery; 13 - facial artery; 14 - vagus nerve; 15 - hypoglossal nerve; 16 - superior laryngeal nerve

Slightly above the origin of the superior thyroid artery at the level of the greater horn of the hyoid bone, immediately below the hypoglossal nerve, on the anterior surface of the external carotid artery is the mouth of the lingual artery (a. lingualis), which is hidden under the outer edge of the hyoid muscle.

At the same level, but from the inner surface of the external carotid artery, the ascending pharyngeal artery (a.pharyngea ascendens) arises.

Above the lingual artery, the facial artery (a.facialis) departs. It is directed upward and medially under the posterior belly of the digastric muscle, pierces the deep layer of the second fascia of the neck and, bending towards the medial side, enters the bed of the submandibular salivary gland (see Fig. 12.4).

At the same level, the sternocleidomastoid artery (a. sternocleidomastoidea) departs from the lateral surface of the external carotid artery.

On the posterior surface of the external carotid artery, at the level of the origin of the facial and sternocleidomastoid arteries, there is the ostium of the occipital artery (a.occipitalis). It runs backward and upward along the lower edge of the posterior belly of the digastric muscle.

Under the posterior belly of the digastric muscle, anterior to the internal carotid artery, is the hypoglossal nerve, which forms an arch with its convexity downward. The nerve runs forward under the lower edge of the digastric muscle.

The superior laryngeal nerve (n. laryngeus superior) is located at the level of the greater horn of the hyoid bone behind both carotid arteries on the prevertebral fascia. It is divided into two branches: internal and external. The internal branch goes down and forward, accompanied by the superior laryngeal artery (a.laryngea superior), located below the nerve. Next, it pierces the thyrohyoid membrane and penetrates the wall of the larynx. The external branch of the superior laryngeal nerve runs vertically downward to the cricothyroid muscle.

The cervical section of the borderline sympathetic trunk is located under the fifth fascia of the neck immediately inward from the palpable anterior tubercles of the transverse processes of the cervical vertebrae. It lies directly on the long muscles of the head and neck. At the level of Th n - Th ni there is the superior cervical sympathetic node, reaching 2-4 cm in length and 5-6 mm in width.

12.3.3. Scapulotracheal triangle

The scapular-tracheal triangle (trigonum omotracheale) is bounded above and behind by the upper belly of the omohyoid muscle, below and behind by the anterior edge of the sternocleidomastoid muscle, and in front by the midline of the neck. The skin is thin, mobile, and stretches easily. The first fascia forms the sheath of the subcutaneous muscle.

The second fascia fuses along the upper border of the area with the hyoid bone, and below it is attached to the anterior surface of the sternum and clavicle. Along the midline, the second fascia fuses with the third, however, for approximately 3 cm upward from the jugular notch, both fascial leaves exist as independent plates and delimit the cellular space (spatium interaponeuroticum suprasternale).

The third fascia has a limited extent: at the top and bottom it is connected with the bony boundaries of the region, and at the sides it ends at the edges of the omohyoid muscles connected to it. Fusing in the upper half of the region with the second fascia along the midline, the third fascia forms the so-called white line of the neck (linea alba colli) 2-3 mm wide.

The third fascia forms the sheath of 4 paired muscles located below the hyoid bone: mm. sternohyoideus, sternothyroideus, thyrohyoideus, omohyoideus.

The sternohyoid and sternothyroid muscles begin with most of their fibers from the sternum. The sternohyoid muscle is longer and narrower, lies closer to the surface, the sternothyroid muscle is wider and shorter, lies deeper and is partially covered by the previous muscle. The sternohyoid muscle is attached to the body of the hyoid bone, converging near the midline with the same muscle on the opposite side; The sternothyroid muscle is attached to the thyroid cartilage, and, going from the sternum upward, it diverges from the same muscle on the opposite side.

The thyrohyoid muscle is to a certain extent a continuation of the sternothyroid muscle and stretches from the thyroid cartilage to the hyoid bone. The scapulohyoid muscle has two bellies - lower and upper, the first being connected to the upper edge of the scapula, the second to the body of the hyoid bone. Between both bellies of the muscle there is an intermediate tendon. The third fascia ends along the outer edge of the muscle, firmly fuses with its intermediate tendon and the wall of the internal jugular vein.

Under the described layer of muscles with their sheaths are the leaves of the fourth fascia of the neck (fascia endocervicalis), which consists of a parietal layer covering the muscles and a visceral one. Under the visceral layer of the fourth fascia are the larynx, trachea, thyroid gland (with parathyroid glands), pharynx, and esophagus.

12.4. TOPOGRAPHY OF THE LARYNX AND CERVICAL TRACHEA

Larynx(larynx) form 9 cartilages (3 paired and 3 unpaired). The base of the larynx is the cricoid cartilage, located at the level of the VI cervical vertebra. Above the anterior part of the cricoid cartilage is the thyroid cartilage. The thyroid cartilage is connected to the hyoid bone by a membrane (membrana hyothyroidea), from the cricoid cartilage to the thyroid cartilage there are mm. cricothyroidei and ligg. cricoarytenoidei.

In the cavity of the larynx, three sections are distinguished: the upper (vestibulum laryngis), the middle, corresponding to the position of the false and true vocal cords, and the lower, called in laryngology the subglottic space (Fig. 12.6, 12.7).

Skeletotopia.The larynx is located from the upper edge of the V cervical vertebra to the lower edge of the VI cervical vertebra. The upper part of the thyroid cartilage can reach the level of the IV cervical vertebra. In children, the larynx lies significantly higher, reaching with its upper edge the level of the III vertebra; in older people it lies low, with its upper edge at the level of the VI vertebra. The position of the larynx changes dramatically in the same person depending on the position of the head. So, with the tongue protruding, the larynx rises, the epiglottis takes a position close to vertical, opening the entrance to the larynx.

Blood supply.The larynx is supplied with blood by branches of the superior and inferior thyroid arteries.

InnervationThe larynx is carried out by the pharyngeal plexus, which is formed by the branches of the sympathetic, vagus and glossopharyngeal nerves. The upper and lower laryngeal nerves (n. laryngeus superior et inferior) are branches of the vagus nerve. In this case, the superior laryngeal nerve, being predominantly sensitive,

innervates the mucous membrane of the upper and middle parts of the larynx, as well as the cricothyroid muscle. The inferior laryngeal nerve, being predominantly motor, innervates the muscles of the larynx and the mucous membrane of the lower part of the larynx.

Rice. 12.6.Organs and blood vessels of the neck:

1 - hyoid bone; 2 - trachea; 3 - lingual vein; 4 - superior thyroid artery and vein; 5 - thyroid gland; 6 - left common carotid artery; 7 - left internal jugular vein; 8 - left anterior jugular vein, 9 - left external jugular vein; 10 - left subclavian artery; 11 - left subclavian vein; 12 - left brachiocephalic vein; 13 - left vagus nerve; 14 - right brachiocephalic vein; 15 - right subclavian artery; 16 - right anterior jugular vein; 17 - brachiocephalic trunk; 18 - the smallest thyroid vein; 19 - right external jugular vein; 20 - right internal jugular vein; 21 - sternocleidomastoid muscle

Rice. 12.7.Cartilages, ligaments and joints of the larynx (from: Mikhailov S.S. et al., 1999) a - front view: 1 - hyoid bone; 2 - granular cartilage; 3 - upper horn of the thyroid cartilage; 4 - left plate of the thyroid cartilage;

5 - lower horn of the thyroid cartilage; 6 - arch of cricoid cartilage; 7 - tracheal cartilage; 8 - annular ligaments of the trachea; 9 - cricothyroid joint; 10 - cricothyroid ligament; 11 - superior thyroid notch; 12 - thyrohyoid membrane; 13 - median thyrohyoid ligament; 14 - lateral thyrohyoid ligament.

6 - rear view: 1 - epiglottis; 2 - greater horn of the hyoid bone; 3 - granular cartilage; 4 - upper horn of the thyroid cartilage; 5 - right plate of the thyroid cartilage; 6 - arytenoid cartilage; 7, 14 - right and left cricoarytenoid cartilages; 8, 12 - right and left cricothyroid joints; 9 - tracheal cartilage; 10 - membranous wall of the trachea; 11 - plate of the cricoid cartilage; 13 - lower horn of the thyroid cartilage; 15 - muscular process of the arytenoid cartilage; 16 - vocal process of the arytenoid cartilage; 17 - thyroepiglottic ligament; 18 - corniculate cartilage; 19 - lateral thyrohyoid ligament; 20 - thyrohyoid membrane

Lymphatic drainage.With regard to lymphatic drainage, it is customary to divide the larynx into two sections: the upper - above the vocal cords and the lower - below the vocal cords. The regional lymph nodes of the upper larynx are mainly the deep cervical lymph nodes located along the internal jugular vein. Lymphatic vessels from the lower part of the larynx end in nodes located near the trachea. These nodes are connected to the deep cervical lymph nodes.

Trachea - is a tube consisting of 15-20 cartilaginous half-rings, making up approximately 2/3-4/5 of the circumference of the trachea and closed at the back by a connective tissue membrane, and interconnected by annular ligaments.

The membranous membrane contains, in addition to elastic and collagen fibers running in the longitudinal direction, also smooth muscle fibers running in the longitudinal and oblique directions.

The inside of the trachea is covered with a mucous membrane, in which the most superficial layer is stratified ciliated columnar epithelium. A large number of goblet cells located in this layer produce, together with the tracheal glands, a thin layer of mucus that protects the mucous membrane. The middle layer of the mucous membrane is called the basement membrane and consists of a network of argyrophilic fibers. The outer layer of the mucous membrane is formed by elastic fibers arranged in the longitudinal direction, especially developed in the area of ​​the membranous part of the trachea. Due to this layer, folding of the mucous membrane is formed. The excretory canaliculi of the tracheal glands open between the folds. Due to the pronounced submucosal layer, the mucous membrane of the trachea is mobile, especially in the area of ​​the membranous part of its wall.

The outside of the trachea is covered with a fibrous sheet, which consists of three layers. The outer leaf is intertwined with fibers with the outer perichondrium, and the inner leaf with the inner perichondrium of cartilaginous semirings. The middle layer is fixed at the edges of the cartilaginous half-rings. Between these layers of fibrous fibers are located adipose tissue, blood vessels and glands.

There are cervical and thoracic sections of the trachea.

The total length of the trachea varies in adults from 8 to 15 cm, in children it varies depending on age. In men it is 10-12 cm, in women - 9-10 cm. The length and width of the trachea in adults depend on the body type. So, with a brachymorphic body type it is short and wide, with a dolichomorphic body type it is narrow and long. In children

During the first 6 months of life, the funnel-shaped shape of the trachea predominates; with age, the trachea acquires a cylindrical or conical shape.

Skeletotopia.The onset of the cervical spine depends on age in children and body type in adults, in whom it ranges from the lower edge of the VI cervical to the lower edge of the II thoracic vertebrae. The boundary between the cervical and thoracic regions is the superior thoracic aperture. According to various researchers, the thoracic trachea can account for 2/5-3/5 in children of the first years of life, and from 44.5-62% of its total length in adults.

Syntopy.In children, a relatively large thymus gland is adjacent to the anterior surface of the trachea, which in young children can rise to the lower edge of the thyroid gland. The thyroid gland in newborns is located relatively high. Its lateral lobes with their upper edges reach the level of the upper edge of the thyroid cartilage, and with their lower edges - 8-10 tracheal rings and almost touch the thymus gland. The isthmus of the thyroid gland in newborns is adjacent to the trachea over a relatively large extent and occupies a higher position. Its upper edge is located at the level of the cricoid cartilage of the larynx, and the lower edge reaches the 5-8th tracheal rings, while in adults it is located between the 1st and 4th rings. The thin pyramidal process is relatively common and is located near the midline.

In adults, the upper part of the cervical trachea is surrounded in front and on the sides by the thyroid gland, and the esophagus is adjacent to it, separated from the trachea by a layer of loose tissue.

The upper cartilages of the trachea are covered by the isthmus of the thyroid gland, in the lower part of the cervical part of the trachea there are the inferior thyroid veins and the unpaired thyroid venous plexus. The upper edge of the left brachiocephalic vein is quite often located above the jugular notch of the manubrium of the sternum in people of brachymorphic body type.

The recurrent laryngeal nerves lie in the esophageal-tracheal grooves formed by the esophagus and trachea. In the lower part of the neck, the common carotid arteries are adjacent to the lateral surfaces of the trachea.

The esophagus is adjacent to the thoracic part of the trachea at the back; in front, at the level of the IV thoracic vertebra, immediately above the bifurcation of the trachea and to the left of it is the aortic arch. On the right and in front, the brachiocephalic trunk covers the right semicircle of the trachea. Here, not far from the trachea, are located the trunk of the right vagus nerve and the superior hollow

vein. Above the aortic arch lies the thymus gland or the fatty tissue that replaces it. To the left of the trachea is the left recurrent laryngeal nerve, and above it is the left common carotid artery. To the right and left of the trachea and below the bifurcation there are numerous groups of lymph nodes.

Along the trachea in front there are suprasternal interaponeurotic, pretracheal and peritracheal cellular spaces containing the unpaired venous plexus of the thyroid gland, the inferior thyroid artery (in 10-12% of cases), lymph nodes, vagus nerves, cardiac branches of the borderline sympathetic trunk.

Blood supplyThe cervical part of the trachea is carried out by the branches of the inferior thyroid arteries or thyrocervical trunks. Blood flow to the thoracic trachea occurs through the bronchial arteries, as well as from the arch and descending part of the aorta. Bronchial arteries in the number of 4 (sometimes 2-6) most often arise from the anterior and right semicircle of the descending part of the thoracic aorta on the left, less often - from 1-2 intercostal arteries or the descending part of the aorta on the right. They can start from the subclavian, inferior thyroid arteries and from the costocervical trunk. In addition to these constant sources of blood supply, there are additional branches extending from the aortic arch, brachiocephalic trunk, subclavian, vertebral, internal thoracic and common carotid arteries.

Before entering the lungs, the bronchial arteries give off parietal branches in the mediastinum (to the muscles, spine, ligaments and pleura), visceral branches (to the esophagus, pericardium), adventitia of the aorta, pulmonary vessels, azygos and semi-gypsy veins, to the trunks and branches of the sympathetic and vagus nerves , as well as to the lymph nodes.

In the mediastinum, the bronchial arteries anastomose with the esophageal, pericardial arteries, branches of the internal thoracic and inferior thyroid arteries.

Venous drainage.The venous vessels of the trachea are formed from intra- and extraorgan venous networks of the mucous, deep submucosal and superficial plexuses. Venous outflow is carried out through the lower thyroid veins, flowing into the azygos thyroid venous plexus, veins of the cervical esophagus, and from the thoracic region - into the azygos and semi-gypsy veins, sometimes into the brachiocephalic veins, and also anastomose with the veins of the thymus, mediastinal tissue, thoracic esophagus .

Innervation.The cervical part of the trachea is innervated by the tracheal branches of the recurrent laryngeal nerves, including branches from the cervical cardiac nerves, cervical sympathetic nodes and internodal branches, and in some cases from the thoracic sympathetic trunk. In addition, sympathetic branches also approach the trachea from the common carotid and subclavian plexuses. Branches from the recurrent laryngeal nerve, from the main trunk of the vagus nerve, and on the left - from the left recurrent laryngeal nerve approach the thoracic trachea on the right. These branches of the vagus and sympathetic nerves form closely interconnected superficial and deep plexuses.

Lymphatic drainage.Lymphatic capillaries form two networks in the tracheal mucosa - superficial and deep. In the submucosa there is a plexus of draining lymphatic vessels. In the muscle layer of the membranous part, lymphatic vessels are located only between individual muscle bundles. In the adventitia, the efferent lymphatic vessels are located in two layers. Lymph from the cervical part of the trachea flows into the lower deep cervical, pretracheal, paratracheal, and retropharyngeal lymph nodes. Some lymphatic vessels carry lymph to the anterior and posterior mediastinal nodes.

The lymphatic vessels of the trachea are connected with the vessels of the thyroid gland, pharynx, trachea and esophagus.

12.5. TOPOGRAPHY OF THE THYROID

AND PARATHYROID GLANDS

The thyroid gland (glandula thyroidea) consists of two lateral lobes and an isthmus. Each lobe of the gland has an upper and lower pole. The upper poles of the lateral lobes of the thyroid gland reach the middle height of the plates of the thyroid cartilage. The lower poles of the lateral lobes of the thyroid gland descend below the isthmus and reach the level of the 5-6 ring, not reaching 2-3 cm from the sternal notch. In approximately 1/3 of cases, the presence of a pyramidal lobe (lobus pyramidalis) extending upward from the isthmus in the form of an additional lobe of the gland is observed. The latter may be connected not with the isthmus, but with the lateral lobe of the gland, and often reaches the hyoid bone. The size and position of the isthmus are highly variable.

The isthmus of the thyroid gland lies anterior to the trachea (at the level of the 1st to 3rd or 2nd to 5th tracheal cartilage). Sometimes (in 10-15% of cases) the isthmus of the thyroid gland is absent.

The thyroid gland has its own capsule in the form of a thin fibrous plate and a fascial sheath formed by the visceral layer of the fourth fascia. Connective tissue septa extend from the capsule of the thyroid gland deep into the parenchyma of the organ. Partitions of the first and second orders are distinguished. Intraorgan blood vessels and nerves pass through the thickness of the connective tissue septa. Between the capsule of the gland and its vagina there is loose tissue in which arteries, veins, nerves and parathyroid glands lie.

In some places, denser fibers depart from the fourth fascia, which have the nature of ligaments passing from the gland to neighboring organs. The median ligament is stretched transversely between the isthmus, on the one hand, and the cricoid cartilage and the 1st tracheal cartilage, on the other. The lateral ligaments run from the gland to the cricoid and thyroid cartilages.

Syntopy.The isthmus of the thyroid gland lies in front of the trachea at the level of the 1st to 3rd or 2nd to 4th cartilage, and often covers part of the cricoid cartilage. The lateral lobes, through the fascial capsule, with their posterolateral surfaces come into contact with the fascial sheaths of the common carotid arteries. The posteromedial surfaces of the lateral lobes are adjacent to the larynx, trachea, tracheoesophageal groove, as well as the esophagus, and therefore, with an increase in the lateral lobes of the thyroid gland, it may be compressed. In the space between the trachea and the esophagus on the right and along the anterior wall of the esophagus on the left, the recurrent laryngeal nerves, lying outside the fascial capsule of the thyroid gland, rise to the cricothyroid ligament. The front of the thyroid gland is covered mm. sternohyoidei, sternothyroidei and omohyoidei.

Blood supplyThe thyroid gland is carried out by branches of four arteries: two aa. thyroideae superiores and two aa. thyroidae inferiores. In rare cases (6-8%), in addition to the indicated arteries, there is a. thyroidea ima, arising from the brachiocephalic trunk or from the aortic arch and heading towards the isthmus.

A. thyroidea superior supplies blood to the upper poles of the lateral lobes and the upper edge of the isthmus of the thyroid gland. A. thyroidea inferior arises from the truncus thyrocervicalis in the scalenovertebral space

and rises under the fifth fascia of the neck along the anterior scalene muscle up to the level of the VI cervical vertebra, forming a loop or arch here. Then it descends downwards and inwards, piercing the fourth fascia, to the lower third of the posterior surface of the lateral lobe of the gland. The ascending part of the inferior thyroid artery runs medially from the phrenic nerve. At the posterior surface of the lateral lobe of the thyroid gland, the branches of the inferior thyroid artery cross the recurrent laryngeal nerve, being anterior or posterior to it, and sometimes encircle the nerve in the form of a vascular loop.

The arteries of the thyroid gland (Fig. 12.8) form two systems of collaterals: intraorgan (due to the thyroid arteries) and extraorganic (due to anastomoses with the vessels of the pharynx, esophagus, larynx, trachea and adjacent muscles).

Venous drainage.The veins form plexuses around the lateral lobes and the isthmus, especially on the anterolateral surface of the gland. The plexus lying on and below the isthmus is called plexus venosus thyreoideus impar. From it arise the inferior thyroid veins, which often flow into the corresponding innominate veins, and the most inferior thyroid veins vv. thyroideae imae (one or two), flowing into the left innominate. The superior thyroid veins drain into the internal jugular vein (directly or through the common facial vein). The inferior thyroid veins are formed from the venous plexus on the anterior surface of the gland, as well as from the unpaired venous plexus (plexus thyroideus impar), located at the lower edge of the isthmus of the thyroid gland and in front of the trachea, and flow into the right and left brachiocephalic veins, respectively. The veins of the thyroid gland form numerous intraorgan anastomoses.

Innervation.The thyroid nerves arise from the borderline trunk of the sympathetic nerve and from the superior and inferior laryngeal nerves. The inferior laryngeal nerve comes into close contact with the inferior thyroid artery, crossing it on its way. Among other vessels, the inferior thyroid artery is ligated when removing the goiter; if the ligation is performed near the gland, then damage to the inferior laryngeal nerve or its involvement in the ligature is possible, which can lead to paresis of the vocal muscles and phonation disorder. The nerve passes either in front of the artery or behind, and on the right it lies more often in front of the artery, and on the left - behind.

Lymphatic drainagefrom the thyroid gland occurs mainly to the nodes located in front and on the sides of the trachea (nodi lymphatici

praetracheales et paratracheales), partially into the deep cervical lymph nodes (Fig. 12.9).

The parathyroid glands (glandulae parathyroideae) are closely related to the thyroid gland. Usually there are 4 in number, they are most often located outside the thyroid capsule.

Rice. 12.8.Sources of blood supply to the thyroid and parathyroid glands: 1 - brachiocephalic trunk; 2 - right subclavian artery; 3 - right common carotid artery; 4 - right internal carotid artery; 5 - right external carotid artery; 6 - left superior thyroid artery; 7 - left inferior thyroid artery; 8 - inferior thyroid artery; 9 - left thyroid-cervical trunk

Rice. 12.9. Lymph nodes of the neck:

1 - pretracheal nodes; 2 - anterior thyroid nodes; 3 - mental nodes, 4 - mandibular nodes; 5 - buccal nodes; 6 - occipital nodes; 7 - parotid nodes; 8 - retroauricular nodes, 9 - upper jugular nodes; 10 - upper nuchal nodes; 11 - lower jugular and supraclavicular nodes

glands (between the capsule and the fascial sheath), two on each side, on the posterior surface of its lateral lobes. There are significant differences in both the number and size, as well as in the position of the parathyroid glands. Sometimes they are located outside the fascial sheath of the thyroid gland. As a result, finding the parathyroid glands during surgical interventions presents significant difficulties, especially due to the fact that next to the parathyroid glands

prominent glands contain formations very similar to them in appearance (lymph nodes, fatty lumps, accessory thyroid glands).

To establish the true nature of the parathyroid gland removed during surgery, a microscopic examination is performed. To prevent complications associated with erroneous removal of the parathyroid glands, it is advisable to use microsurgical techniques and instruments.

12.6. Sternoclavicular-mastoid region

The sternocleidomastoid region (regio sternocleidomastoidea) corresponds to the position of the muscle of the same name, which is the main external landmark. The sternocleidomastoid muscle covers the medial neurovascular bundle of the neck (common carotid artery, internal jugular vein and vagus nerve). In the carotid triangle, the neurovascular bundle is projected along the anterior edge of this muscle, and in the lower part it is covered by its sternal portion.

At the middle of the posterior edge of the sternocleidomastoid muscle, the exit site of the sensory branches of the cervical plexus is projected. The largest of these branches is the great auricular nerve (n. auricularis magnus). The venous angle of Pirogov, as well as the vagus and phrenic nerves, are projected between the legs of this muscle.

Leatherthin, easily folded together with subcutaneous tissue and superficial fascia. Near the mastoid process, the skin is dense and inactive.

Subcutaneous fat loose. At the upper border of the area, it thickens and becomes cellular due to connective tissue bridges connecting the skin with the periosteum of the mastoid process.

Between the first and second fascia of the neck are the external jugular vein, superficial cervical lymph nodes and cutaneous branches of the cervical plexus of spinal nerves.

The external jugular vein (v. jugularis extema) is formed by the confluence of the occipital, auricular and partially mandibular veins at the angle of the mandible and is directed downward, obliquely crossing m. sternocleidomastoideus, to the apex of the angle formed by the posterior edge of the sternocleidomastoid muscle and the upper edge of the clavicle.

Rice. 12.10.Arteries of the head and neck (from: Sinelnikov R.D., 1979): 1 - parietal branch; 2 - frontal branch; 3 - zygomaticoorbital artery; 4 - supraorbital artery; 5 - supratrochlear artery; 6 - ophthalmic artery; 7 - artery of the dorsum of the nose; 8 - sphenopalatine artery; 9 - angular artery; 10 - infraorbital artery; 11 - posterior superior alveolar artery;

12 - buccal artery; 13 - anterior superior alveolar artery; 14 - superior labial artery; 15 - pterygoid branches; 16 - artery of the back of the tongue; 17 - deep artery of the tongue; 18 - inferior labial artery; 19 - mental artery; 20 - inferior alveolar artery; 21 - hypoglossal artery; 22 - submental artery; 23 - ascending palatine artery; 24 - facial artery; 25 - external carotid artery; 26 - lingual artery; 27 - hyoid bone; 28 - suprahyoid branch; 29 - sublingual branch; 30 - superior laryngeal artery; 31 - superior thyroid artery; 32 - sternocleidomastoid branch; 33 - cricoid-thyroid branch; 34 - common carotid artery; 35 - inferior thyroid artery; 36 - thyrocervical trunk; 37 - subclavian artery; 38 - brachiocephalic trunk; 39 - internal mammary artery; 40 - aortic arch; 41 - costocervical trunk; 42 - suprascapular artery; 43 - deep artery of the neck; 44 - superficial branch; 45 - vertebral artery; 46 - ascending artery of the neck; 47 - spinal branches; 48 - internal carotid artery; 49 - ascending pharyngeal artery; 50 - posterior auricular artery; 51 - stylomastoid artery; 52 - maxillary artery; 53 - occipital artery; 54 - mastoid branch; 55 - transverse artery of the face; 56 - deep auricular artery; 57 - occipital branch; 58 - anterior tympanic artery; 59 - chewing artery; 60 - superficial temporal artery; 61 - anterior auricular branch; 62 - middle temporal artery; 63 - middle meningeal artery artery; 64 - parietal branch; 65 - frontal branch

Here the external jugular vein, perforating the second and third fascia of the neck, goes deep and flows into the subclavian or internal jugular vein.

The great auricular nerve runs along with the external jugular vein posterior to it. It innervates the skin of the mandibular fossa and the angle of the mandible. The transverse nerve of the neck (n. transversus colli) crosses the middle of the outer surface of the sternocleidomastoid muscle and at its anterior edge is divided into superior and inferior branches.

The second fascia of the neck forms an isolated sheath for the sternocleidomastoid muscle. The muscle is innervated by the external branch of the accessory nerve (n. accessories). Inside the fascial sheath of the sternocleidomastoid muscle, the small occipital nerve (n. occipitalis minor) rises upward along its posterior edge, innervating the skin of the mastoid region.

Behind the muscle and its fascial sheath there is a carotid neurovascular bundle, surrounded by the parietal layer of the fourth fascia of the neck. Inside the bundle, the common carotid artery is located medially, the internal jugular vein is located laterally, and the vagus nerve is located between them and posteriorly.

Rice. 12.11.Veins of the neck (from: Sinelnikov R.D., 1979)

1 - parietal veins-graduates; 2 - superior sagittal sinus; 3 - cavernous sinus; 4 - supratrochlear vein; 5 - nasofrontal vein; 6 - superior ophthalmic vein; 7 - external nasal vein; 8 - angular vein; 9 - pterygoid venous plexus; 10 - facial vein; 11 - superior labial vein; 12 - transverse vein of the face; 13 - pharyngeal vein; 14 - lingual vein; 15 - inferior labial vein; 16 - mental vein; 17 - hyoid bone; 18 - internal jugular vein; 19 - superior thyroid vein; 20 - front

jugular vein; 21 - inferior bulb of the internal jugular vein; 22 - inferior thyroid vein; 23 - right subclavian vein; 24 - left brachiocephalic vein; 25 - right brachiocephalic vein; 26 - internal mammary vein; 27 - superior vena cava; 28 - suprascapular vein; 29 - transverse vein of the neck; 30 - vertebral vein; 31 - external jugular vein; 32 - deep vein of the neck; 33 - external vertebral plexus; 34 - retromandibular vein; 35 - occipital vein; 36 - mastoid venous outlet; 37 - posterior auricular vein; 38 - occipital venous outlet; 39 - superior bulb of the internal jugular vein; 40 - sigmoid sinus; 41 - transverse sinus; 42 - occipital sinus; 43 - inferior petrosal sinus; 44 - sinus drain; 45 - superior petrosal sinus; 46 - direct sine; 47 - great vein of the brain; 48 - superficial temporal vein; 49 - inferior sagittal sinus; 50 - sickle brain; 51 - diploic veins

The cervical sympathetic trunk (truncus sympathicus) is located parallel to the common carotid artery under the fifth fascia, but deeper and medial.

Branches of the cervical plexus (plexus cervicalis) emerge from under the sternocleidomastoid muscle. It is formed by the anterior branches of the first 4 cervical spinal nerves and lies on the side of the transverse processes of the vertebrae between the vertebral (posterior) and prevertebral (anterior) muscles. The branches of the plexus include:

Lesser occipital nerve (n. occipitalis minor), extends upward to the mastoid process and further into the lateral parts of the occipital region; innervates the skin of this area;

The great auricular nerve (n.auricularis magnus) runs up and anteriorly along the anterior surface of the sternocleidomastoid muscle, covered with the second fascia of the neck; innervates the skin of the auricle and the skin over the parotid salivary gland;

The transverse nerve of the neck (n. transversus colli) runs anteriorly, crossing the sternocleidomastoid muscle, at its anterior edge it is divided into upper and lower branches that innervate the skin of the anterior neck;

Supraclavicular nerves (nn. supraclaviculares), 3-5 in number, spread fan-shaped down between the first and second fascia of the neck, branching in the skin of the posterior lower part of the neck (lateral branches) and the upper anterior surface of the chest to the third rib (medial branches);

The phrenic nerve (n. phrenicus), predominantly motor, goes down the anterior scalene muscle into the chest cavity, where it passes to the diaphragm in front of the roots of the lungs between

mediastinal pleura and pericardium; innervates the diaphragm, gives off sensory branches to the pleura and pericardium, sometimes to the cervicothoracic nerve plexus;

The lower root of the cervical loop (r.inferior ansae cervicalis) goes anteriorly to connect with the upper root arising from the hypoglossal nerve;

Muscular branches (rr. musculares) go to the vertebral muscles, the levator scapulae muscle, the sternocleidomastoid and trapezius muscles.

Between the deep (posterior) surface of the lower half of the sternocleidomastoid muscle with its fascial sheath and the anterior scalene muscle, covered with the fifth fascia, the prescalene space (spatium antescalenum) is formed. Thus, the prescalene space is limited anteriorly by the second and third fascia, and posteriorly by the fifth fascia of the neck. The carotid neurovascular bundle is located medially in this space. The internal jugular vein lies here not only lateral to the common carotid artery, but also somewhat anterior (more superficial). Here its bulb (lower extension; bulbus venae jugularis inferior) connects with the subclavian vein approaching from the outside. The vein is separated from the subclavian artery by the anterior scalene muscle. Immediately outward from the confluence of these veins, called the venous angle of Pirogov, the external jugular vein flows into the subclavian vein. On the left, the thoracic (lymphatic) duct flows into the venous angle. United v. jugularis intema and v. subclavia give rise to the brachiocephalic vein. The suprascapular artery (a. suprascapularis) also passes through the prescalene interval in the transverse direction. Here, on the anterior surface of the anterior scalene muscle, under the fifth fascia of the neck, the phrenic nerve passes.

Behind the anterior scalene muscle, under the fifth fascia of the neck, is the interscalene space (spatium interscalenum). The interscalene space is limited posteriorly by the middle scalene muscle. In the interscalene space the trunks of the brachial plexus pass above and laterally, below - a. subclavia.

The scalene-vertebral space (triangle) is located behind the lower third of the sternocleidomastoid muscle, under the fifth fascia of the neck. Its base is the dome of the pleura, the apex is the transverse process of the VI cervical vertebra. Posteriorly and medially it is limited by the vertebral column

com with the longus colli muscle, and anteriorly and laterally - with the medial edge of the anterior scalene muscle. Under the prevertebral fascia there is the contents of the space: the beginning of the cervical subclavian artery with branches extending here from it, the arch of the thoracic (lymphatic) duct, ductus thoracicus (on the left), the lower and cervicothoracic (stellate) nodes of the sympathetic trunk.

Topography of vessels and nerves. The subclavian arteries are located under the fifth fascia. The right subclavian artery (a. subclavia dextra) arises from the brachiocephalic trunk, and the left (a. subclavia sinistra) arises from the aortic arch.

The subclavian artery is conventionally divided into 4 sections:

Thoracic - from the origin to the medial edge (m. scalenus anterior);

Interscalene, corresponding to the interscalene space (spatium interscalenum);

Supraclavicular region - from the lateral edge of the anterior scalene muscle to the clavicle;

Subclavian - from the collarbone to the upper edge of the pectoralis minor muscle. The last section of the artery is called the axillary artery, and it is studied in the subclavian region in the clavipectoral triangle (trigonum clavipectorale).

In the first section, the subclavian artery lies on the dome of the pleura and is connected to it by connective tissue cords. On the right side of the neck, anterior to the artery, there is the venous angle of Pirogov - the confluence of the subclavian vein and the internal jugular vein. Along the anterior surface of the artery, the vagus nerve descends transversely to it, from which the recurrent laryngeal nerve departs here, bending around the artery from below and behind and rising upward in the corner between the trachea and the esophagus. Outside the vagus nerve, the artery is crossed by the right phrenic nerve. Between the vagus and phrenic nerves is the subclavian loop of the sympathetic trunk (ansa subclavia). The right common carotid artery passes inward from the subclavian artery.

On the left side of the neck, the first section of the subclavian artery lies deeper and is covered by the common carotid artery. Anterior to the left subclavian artery is the internal jugular vein and the beginning of the left brachiocephalic vein. The vagus and left phrenic nerves pass between these veins and the artery. Medial to the subclavian artery are the esophagus and trachea, and in the groove between them is the left

recurrent laryngeal nerve. Between the left subclavian and common carotid arteries, bending around the subclavian artery from behind and above, the thoracic lymphatic duct passes.

Branches of the subclavian artery (Fig. 12.13). The vertebral artery (a. vertebralis) arises from the superior semicircle of the subclavian medial to the inner edge of the anterior scalene muscle. Rising upward between this muscle and the outer edge of the longus colli muscle, it enters the opening of the transverse process of the VI cervical vertebra and further upwards in the bone canal formed by the transverse processes of the cervical vertebrae. Between the I and II vertebrae it emerges from the canal. Next, the vertebral artery enters the cranial cavity through the great

Rice. 12.13.Branches of the subclavian artery:

1 - internal mammary artery; 2 - vertebral artery; 3 - thyrocervical trunk; 4 - ascending cervical artery; 5 - inferior thyroid artery; 6 - inferior laryngeal artery; 7 - suprascapular artery; 8 - costocervical trunk; 9 - deep cervical artery; 10 - the uppermost intercostal artery; 11 - transverse artery of the neck

hole. In the cranial cavity at the base of the brain, the right and left vertebral arteries merge into one basilar artery (a. basilaris), which participates in the formation of the circle of Willis.

Internal thoracic artery, a. thoracica interna, directed downwards from the lower semicircle of the subclavian artery opposite the vertebral artery. Having passed between the dome of the pleura and the subclavian vein, it descends to the posterior surface of the anterior chest wall.

The thyroid trunk (truncus thyrocervicalis) departs from the subclavian artery at the medial edge of the anterior scalene muscle and gives off 4 branches: the inferior thyroid (a. thyroidea inferior), the ascending cervical (a. cervicalis ascendens), the suprascapularis (a. suprascapularis) and the transverse cervical artery ( a. transversa colli).

A. thyroidea inferior, rising upward, forms an arch at the level of the transverse process of the VI cervical vertebra, crossing the vertebral artery lying behind and the common carotid artery passing in front. From the inferomedial part of the arch of the inferior thyroid artery branches extend to all organs of the neck: rr. pharyngei, oesophagei, tracheales. In the walls of the organs and the thickness of the thyroid gland, these branches anastomose with the branches of other arteries of the neck and the branches of the opposite lower and upper thyroid arteries.

A. cervicalis ascendens goes upward along the anterior surface of m. scalenus anterior, parallel to n. phrenicus, inward from him.

A. suprascapularis is directed to the lateral side, then, with the vein of the same name, it is located behind the upper edge of the clavicle and together with the lower abdomen of m. omohyoideus reaches the transverse notch of the scapula.

A. transversa colli can arise from both the truncus thyrocervicalis and the subclavian artery. The deep branch of the transverse artery of the neck, or the dorsal artery of the scapula, lies in the cellular space of the back at the medial edge of the scapula.

The costocervical trunk (truncus costocervicalis) most often arises from the subclavian artery. Having passed upward along the dome of the pleura, it is divided at the spine into two branches: the uppermost - intercostal (a. intercostalis suprema), reaching the first and second intercostal spaces, and the deep cervical artery (a. cervicalis profunda), penetrating the muscles of the back of the neck.

The cervicothoracic (stellate) node of the sympathetic trunk is located behind the internal

semicircle of the subclavian artery, the vertebral artery arising medially from it. It is formed in most cases from the connection of the lower cervical and first thoracic nodes. Moving onto the wall of the vertebral artery, the branches of the stellate ganglion form the periarterial vertebral plexus.

12.7. LATERAL NECK AREA

12.7.1. Scapular-trapezoid triangle

The scapular-trapezoid triangle (trigonum omotrapecoideum) is bounded below by the scapular-hyoid muscle, in front by the posterior edge of the sternocleidomastoid muscle, and behind by the anterior edge of the trapezius muscle (Fig. 12.14).

Leatherthin and mobile. Innervated by the lateral branches of the supraclavicular nerves (nn. supraclaviculares laterals) from the cervical plexus.

Subcutaneous fat loose.

The superficial fascia contains fibers of the superficial neck muscle. Under the fascia there are cutaneous branches. The external jugular vein (v. jugularis externa), crossing from top to bottom and outwards the middle third of the sternocleidomastoid muscle, exits to the lateral surface of the neck.

The superficial layer of the neck's own fascia forms the sheath for the trapezius muscle. Between it and the deeper prevertebral fascia there is an accessory nerve (n. accessorius), which innervates the sternocleidomastoid and trapezius muscles.

The brachial plexus (plexus brachialis) is formed by the anterior branches of the 4 lower cervical spinal nerves and the anterior branch of the first thoracic spinal nerve.

The supraclavicular part of the plexus is located in the lateral triangle of the neck. It consists of three trunks: upper, middle and lower. The upper and middle trunks lie in the interscalene fissure above the subclavian artery, and the lower one lies behind it. Short branches of the plexus extend from the supraclavicular part:

The dorsal nerve of the scapula (n. dorsalis scapulae) innervates the levator scapulae muscle, the rhomboid major and minor muscles;

The long thoracic nerve (n. thoracicus longus) innervates the serratus anterior muscle;

The subclavian nerve (n. subclavius) innervates the subclavian muscle;

The subscapular nerve (n. subscapularis) innervates the teres major and minor muscles;

Rice. 12.14.Topography of the lateral triangle of the neck:

1 - Sternocleidomastoid muscle; 2 - trapezius muscle, 3 - subclavian muscle; 4 - anterior scalene muscle; 5 - middle scalene muscle; 6 - posterior scalene muscle; 7 - subclavian vein; 8 - internal jugular vein; 9 - thoracic lymphatic duct; 10 - subclavian artery; 11 - thyrocervical trunk; 12 - vertebral artery; 13 - ascending cervical artery; 14 - inferior thyroid artery; 15 - suprascapular artery; 16 - superficial cervical artery; 17 - suprascapular artery; 18 - cervical plexus; 19 - phrenic nerve; 20 - brachial plexus; 19 - accessory nerve

The pectoral nerves, medial and lateral (nn. pectorales medialis et lateralis) innervate the pectoralis major and minor muscles;

The axillary nerve (n.axillaris) innervates the deltoid and teres minor muscles, the capsule of the shoulder joint and the skin of the outer surface of the shoulder.

12.7.2. Scapuloclavicular triangle

In the scapuloclavicular triangle (trigonum omoclavicularis), the lower border is the clavicle, the anterior border is the posterior edge of the sternocleidomastoid muscle, the superoposterior border is the projection line of the lower belly of the scapulohyoid muscle.

Leatherthin, mobile, innervated by supraclavicular nerves from the cervical plexus.

Subcutaneous fat loose.

The superficial fascia of the neck contains fibers of the subcutaneous muscle of the neck.

The superficial layer of the fascia propria of the neck is attached to the anterior surface of the clavicle.

The deep layer of the neck's own fascia forms the fascial sheath for the omohyoid muscle and is attached to the posterior surface of the clavicle.

Fatty tissue is located between the third fascia of the neck (in front) and the prevertebral fascia (in back). It spreads in the gap: between the first rib and the clavicle with the subclavian muscle adjacent below, between the clavicle and the sternocleidomastoid muscle in front and the anterior scalene muscle in the back, between the anterior and middle scalene muscles.

The neurovascular bundle is represented by the subclavian vein (v. subclavia), located most superficially in the prescalene space. Here it merges with the internal jugular vein (v. jugularis interna), and also receives the anterior and external jugular and vertebral veins. The walls of the veins in this area are fused with the fascia, so when injured, the vessels gape, which can lead to an air embolism during a deep breath.

The subclavian artery (a. subclavia) lies in the interscalene space. Behind it is the posterior bundle of the brachial plexus. The superior and middle bundles are located above the artery. The artery itself is divided into three sections: before entering the interscalene

space, in the interstitial space, at the exit from it to the edge of the first rib. Behind the artery and the inferior bundle of the brachial plexus is the dome of the pleura. The phrenic nerve passes through the prescalene space (see above), crossing the subclavian artery in front.

The thoracic duct (ductus thoracicus) flows into the venous jugular angles, formed by the confluence of the internal jugular and subclavian veins, on the left, and the right lymphatic duct (ductus lymphaticus dexter) flows into the right.

The thoracic duct, emerging from the posterior mediastinum, forms an arch on the neck that rises to the VI cervical vertebra. The arc is directed to the left and forward, located between the left common carotid and subclavian arteries, then between the vertebral artery and the internal jugular vein and before entering the venous angle it forms an extension - the lymphatic sinus (sinus lymphaticus). The duct can flow both into the venous angle and into the veins that form it. Sometimes, before entering, the thoracic duct splits into several smaller ducts.

The right lymphatic duct has a length of up to 1.5 cm and is formed from the confluence of the jugular, subclavian, internal thoracic and bronchomediastinal lymphatic trunks.

12.8. TEST TASKS

12.1. The anterior region of the neck includes three paired triangles from the following:

1. Scapuloclavicular.

2. Scapular-tracheal.

3. Scapular-trapezoidal.

4. Submandibular.

5. Sleepy.

12.2. The lateral region of the neck includes two of the following triangles:

1. Scapuloclavicular.

2. Scapular-tracheal.

3. Scapular-trapezoidal.

4. Submandibular.

5. Sleepy.

12.3. The sternocleidomastoid region is located between:

1. The front and back of the neck.

2. Anterior and lateral area of ​​the neck.

3. Lateral and posterior neck area.

12.4. The submandibular triangle is limited by:

1. From above.

2. Front.

3. Behind and below.

A. Posterior belly of the digastric muscle. B. Edge of the lower jaw.

B. Anterior belly of the digastric muscle.

12.5. The sleepy triangle is limited:

1. From above.

2. From below.

3. Behind.

A. Upper belly of the omohyoid muscle. B. Sternocleidomastoid muscle.

B. Posterior belly of the digastric muscle.

12.6. The scapulotracheal triangle is limited by:

1. Medially.

2. Superior and lateral.

3. Below and laterally.

A. Sternocleidomastoid muscle.

B. Upper belly of the omohyoid muscle.

B. Midline of the neck.

12.7. Determine the sequence of location from the surface to the depth of 5 fascia of the neck:

1. Intracervical fascia.

2. Scapuloclavicular fascia.

3. Superficial fascia.

4. Prevertebral fascia.

5. Own fascia.

12.8. Within the submandibular triangle there are two of the following fascia:

1. Superficial fascia.

2. Own fascia.

4. Intracervical fascia.

5. Prevertebral fascia.

12.9. Within the carotid triangle there are 4 fascias listed:

1. Superficial fascia.

2. Own fascia.

3. Scapuloclavicular fascia.

4. Parietal leaf of the intracervical fascia.

5. Visceral layer of the intracervical fascia.

6. Prevertebral fascia.

12.10. Within the scapulotracheal triangle there are the following fascia:

1. Superficial fascia.

2. Own fascia.

3. Scapuloclavicular fascia.

4. Intracervical fascia.

5. Prevertebral fascia.

12.11. Within the scapular-trapezoid triangle there are 3 fascias listed:

1. Superficial fascia.

2. Own fascia.

3. Scapuloclavicular fascia.

4. Intracervical fascia.

5. Prevertebral fascia.

12.12. Within the scapuloclavicular triangle there are 4 fascias listed:

1. Superficial fascia.

2. Own fascia.

3. Scapuloclavicular fascia.

4. Intracervical fascia.

5. Prevertebral fascia.

12.13. The submandibular salivary gland is located in the fascial bed formed by:

1. Superficial fascia.

2. Own fascia.

3. Scapuloclavicular fascia.

4. Intracervical fascia.

5. Prevertebral fascia.

12.14. A patient with cancer of the lower lip was found to have metastasis in the submandibular salivary gland, which was a consequence of metastasis of cancer cells:

1. Along the excretory duct of the gland.

2. Along the tributaries of the facial vein, into which venous blood flows from both the lower lip and the gland.

3. Through the lymphatic vessels of the gland through the lymph nodes located near the gland.

4. Through the lymphatic vessels into the lymph nodes located in the substance of the gland.

12.15. When removing the submandibular salivary gland, a complication in the form of severe bleeding is possible due to damage to the artery adjacent to the gland:

1. Ascending pharyngeal.

2. Facial.

3. Submental.

4. Lingual.

12.16. The suprasternal interaponeurotic space is located between:

1. Superficial and intrinsic fascia of the neck.

2. Proper and scapuloclavicular fascia.

3. Scapuloclavicular and intracervical fascia.

4. Parietal and visceral layers of the intracervical fascia.

12.17. In the fatty tissue of the suprasternal interaponeurotic space there are:

1. Left brachiocephalic vein.

2. External jugular vein.

4. Jugular venous arch.

12.18. When performing a lower tracheostomy, the surgeon, passing the suprasternal interaponeurotic space, must be careful of damage to:

1. Arterial vessels.

2. Venous vessels.

3. Vagus nerve.

4. Phrenic nerve.

5. Esophagus.

12.19. The previsceral space is located between:

2. Scapuloclavicular and intracervical fascia.

4. Intracervical and prevertebral fascia.

12.20. The retrovisceral space is located between:

3. Prevertebral fascia and spine.

12.21. A seriously ill patient was admitted to the hospital with posterior purulent mediastinitis as a complication of a retropharyngeal abscess. Determine the anatomical route of spread of purulent infection into the mediastinum:

1. Suprasternal interaponeurotic space.

2. Previsceral space.

3. Prevertebral space.

4. Retrovisceral space.

5. Neurovascular sheath.

12.22. The pretracheal space is located between:

1. Proprietary and scapuloclavicular fascia.

2. Scapuloclavicular fascia and parietal layer of intracervical fascia.

3. Parietal and visceral layers of the intracervical fascia.

4. Intracervical and prevertebral fascia.

12.23. When performing a lower tracheostomy using the midline approach, severe bleeding suddenly occurred after penetration into the pretracheal space. Identify the damaged artery:

1. Ascending cervical artery.

2. Inferior laryngeal artery.

3. Inferior thyroid artery.

4. Inferior thyroid artery.

12.24. In the pretracheal space there are two of the following formations:

1. Internal jugular veins.

2. Common carotid arteries.

3. Unpaired thyroid venous plexus.

4. Inferior thyroid arteries.

5. Inferior thyroid artery.

6. Anterior jugular veins.

12.25. Posterior to the larynx are:

1. Pharynx.

2. Share of the thyroid gland.

3. Parathyroid glands.

4. Esophagus.

5. Cervical spine.

12.26. On the side of the larynx there are two of the following anatomical structures:

1. Sternohyoid muscle.

2. Sternothyroid muscle.

3. Share of the thyroid gland.

4. Parathyroid glands.

5. Isthmus of the thyroid gland.

6. Thyrohyoid muscle.

12.27. In front of the larynx there are 3 anatomical structures from the following:

1. Pharynx.

2. Sternohyoid muscle.

3. Sternothyroid muscle.

4. Share of the thyroid gland.

5. Parathyroid glands.

6. Isthmus of the thyroid gland.

7. Thyrohyoid muscle.

12.28. In relation to the cervical spine, the larynx is located at the level of:

12.29. The sympathetic trunk in the neck is located between:

1. Parietal and visceral layers of the intracervical fascia.

2. Intracervical and prevertebral fascia.

3. Prevertebral fascia and longus colli muscle.

12.30. The vagus nerve, being in the same fascial sheath with the common carotid artery and internal jugular vein, is located in relation to these blood vessels:

1. Medial to the common carotid artery.

2. Lateral to the internal jugular vein.

3. Anteriorly between artery and vein.

4. Posteriorly between artery and vein.

5. Anterior to the internal jugular vein.

12.31. The paired muscles located in front of the trachea include two of the following:

1. Sternocleidomastoid.

2. Sternohyoid.

3. Sternothyroid.

4. Scapular-hyoid.

5. Thyrohyoid.

12.32. The cervical part of the trachea includes:

1. 3-5 cartilaginous rings.

2. 4-6 cartilaginous rings.

3. 5-7 cartilaginous rings.

4. 6-8 cartilaginous rings.

5. 7-9 cartilaginous rings.

12.33. Within the neck, the esophagus is closely adjacent to the posterior wall of the trachea:

1. Strictly along the midline.

2. Protruding slightly to the left.

3. Protruding slightly to the right.

12.34. The parathyroid glands are located:

1. On the fascial sheath of the thyroid gland.

2. Between the fascial sheath and the capsule of the thyroid gland.

3. Under the capsule of the thyroid gland.

12.35. With subtotal resection of the thyroid gland, the part of the gland containing the parathyroid glands should be left. This part is:

1. Upper pole of the lateral lobes.

2. Postinternal part of the lateral lobes.

3. Posterolateral part of the lateral lobes.

4. Anterointernal part of the lateral lobes.

5. Anterior outer part of the lateral lobes.

6. Lower pole of the lateral lobes.

12.36. During the strumectomy operation, performed under local anesthesia, when clamps were applied to the blood vessels of the thyroid gland, the patient developed hoarseness due to:

1. Impaired blood supply to the larynx.

2. Compression of the superior laryngeal nerve.

3. Compression of the recurrent laryngeal nerve.

12.37. In the main neurovascular bundle of the neck, the common carotid artery and internal jugular vein are located relative to each other as follows:

1. The artery is medial, the vein is lateral.

2. The artery is lateral, the vein is medial.

3. Artery in front, vein in back.

4. Artery at the back, vein at the front.

12.38. The victim is bleeding heavily from deep in the neck. In order to ligate the external carotid artery, the surgeon exposed in the carotid triangle the place where the common carotid artery divides into external and internal. Determine the main feature by which you can distinguish these arteries from each other:

1. The internal carotid artery is larger than the external one.

2. The beginning of the internal carotid artery is located deeper and outside the beginning of the external one.

3. Lateral branches arise from the external carotid artery.

12.39. The prescalene space is located between:

1. Sternocleidomastoid and anterior scalene muscles.

2. Longus colli muscle and anterior scalene muscle.

3. Anterior and middle scalene muscles.

12.40. In the pre-scalene space there are:

1. Subclavian artery.

2. Subclavian vein.

3. Brachial plexus.

4. Vertebral artery.

12.41. Directly behind the collarbone are:

1. Subclavian artery.

2. Subclavian vein.

3. Brachial plexus.

12.42. The interscalene space is located between:

1. Anterior and middle scalene muscles.

2. Middle and posterior scalene muscles.

3. Scalene muscles and spine.

12.43. In relation to the phrenic nerve, the following statements are correct:

1. Located on the sternocleidomastoid muscle above its own fascia.

2. Located on the sternocleidomastoid muscle under its own fascia.

3. Located on the anterior scalene muscle over the prevertebral fascia.

4. Located on the anterior scalene muscle under the prevertebral fascia.

5. Located on the middle scalene muscle over the prevertebral fascia.

6. Located on the middle scalene muscle under the prevertebral fascia.

12.44. In the interstitial space there are:

1. Subclavian artery and vein.

2. Subclavian artery and brachial plexus.