Alam mo gusto ko sanang mag pulis….…para ikaw ang MOST WANTED KO!Alam mo gusto ko sanang mag pulis….…para ikaw ang MOST WANTED KO!

ALAM MO GUSTO KO SANANG MAGING PULIS,

… PARA IKAW ANG MOST WANTED KO.

PAG IKAW ANG KASAMA KO …

TINATAMAD AKO …

… KASE ANG SARAP MAGPAHINGA SA PILING MO.

SANA ULAN KA AT LUPA NA LANG AKO

… PARA KAHIT GAANO KALAKAS ANG PATAK MO, SA AKIN PA RIN ANG BAGSAK MO.

BAGYO KA BA?

KASI THE MOMENT YOU LEFT MY AREA OF RESPONSIBILITY, YOU LEAVE MY HEART IN A STATE OF CALAMITY

HINDI KA NAMAN KAMERA …

PERO TUWING NAKIKITA KITA, NAPAPANGITI AKO.

SURGICAL ANATOMY OF THE NECK

ELMO R. LAGO JR. MD FPCS FPSO-HNS

OUR LADY OF LOURDES HOSPITAL

OBJECTIVES

GENERAL OBJECTIVE– TO KNOW THE SURGICAL ANATOMY OF THE

NECK

SPECIFIC OBJECTIVES– TO KNOW THE BASIC TERMINOLOGIES

USED IN DESCRIBE STRUCTURES OF THE NECK

– TO KNOW THE FASCIA OF THE NECK– TO KNOW THE DIFFERENT TRAINGLES OF THE

NECK AND DETERMIINE THEIR SIGNIFICANCE– TO KNOW THE CERVICAL LYMPHATICS OF THE

NECK AND THEIR SIGNIFICANCE

ANATOMICAL TERMINOLOGIES

UNDERSTANDING THE TERMS IS VERY CRITICAL TO UNDERSTANDING ANATOMY. LANGUAGE USED TO COMMUNICATE STRUCTURES.

MAKES USE OF THE “STANDARD ANATOMICAL POSITION” AS THE BASIS OF TERMS

PLANES AND TERMINOLOGIES

MIDSAGITTAL PLANE – VERTICAL PLANE PASSING THE CENTER OF THE BODY DIVIDING THE BODY INTO EQUAL LEFT AND RIGHT HALVES

MEDIAL – NEARER THE MIDSAGITTAL PLANELATERAL – AWAY THE MIDSAGITTAL PLANE

CORONAL PLANE – VERTICAL PLANE RUNNING PERPENDICULAR TO THE MIDSAGITTAL PLANE AND DIVIDES THE BODY TO A FRONT AND A BACK

ANTERIOR – GOING FRONTPOSTERIOR – GOING BACK

PLANES AND TERMINOLOGIES

TRANSVERSE PLANE – IT IS A HORIZONTAL PLANE RUNNING PERPENDICULAR TO THE FIRST TWO PLANES AND DIVIDES THE BODY INTO A UPPER AND LOWER PART.

SUPERIOR – GOING CRANIAL

INFERIOR – GOING CAUDAL

PLANES AND TERMINOLOGIES

THE NECK

THE NECK IS THAT REGION OF THE BODY LOCATED BETWEEN THE MANDIBLE ABOVE AND THE CLAVICLE BELOW. IT IS ENCLOSED SUPERFICIALLY BY THE SKIN AND ITS UNDERLYING FASCIA

THE FASCIA CAN BE GROUPED INTO A SUPERFICIAL CERVICAL AND A DEEP CERVICAL FASCIA.

SUPERFICIAL CERVICAL FASCIA – ENCLOSES THE PLATYSMA, CUTANEOUS NERVES, EXTERNAL JUGULAR VEIN AND ANTERIOR JUGULAR VEIN AND SUPERFICIAL LYMPH NODES

THE DEEP CERVICAL FASCIA

3 LAYERS:

1. INVESTING – SURROUNDS THE NECK, ENCLOSES

THE SCM AND TRAPEZIUS MUSCLES

2. PRETRACHEAL – SURROUNDS THE STRAP MUSCLES (INFRAHYOID MUSCLES) AND THE VISCERA OF THE NECK (LARYNX, THYROID)

3. PREVERTEBRAL – SURROUNDS THE CERVICAL VERTEBRAE AND THE NECK MUSCLES

THE CAROTID SHEATH IS FORMED BY CONTRIBUTIONS FROM THE 3 LAYERS OF DEEP FASCIA.THIS SHEATH ENVELOPS THE Internal Jugular Vein, Common Carotid Artery, AND VAGUS NERVE

SUPERFICIAL AND DEEP CERVICAL FASCIA

CLINICAL TRIANGLES AND MUSCLES OF

THE NECK

• ANTERIOR TRIANGLE

• POSTERIOR TRIANGLE

TRIANGLE STRUCTURES

SUBMENTAL SUBMENTAL LYMPH NODES, SUBMENTAL FAT, GH

SUBMANDIBULARSUBMANDIBULAR GLAND, SUBMANDIBULAR LYMPH NODES, FACIAL ARTERY, WHARTON’S DUCT, MH

CAROTIDCOMMON CAROTID ARTERY, INTERNAL JUGULAR VEIN, VAGUS NERVE, JUGULAR NODES

MUSCULARHYOID, THYROID CARTILAGE, CRICOID CARILAGE, TRACHEA, THYROID GLAND, OMOHYOID, STERNOHYOID, STERNOTHYROID, THYROHOID

OCCIPITAL

SPINAL ACCESSORY NERVE, FAT, POSTERIOR GROUP OF NODES

SUPRACLAVICULAR

TIP OF THE LUNG, SUPRACLAVICULAR LYMPH NODES

PALPATING THE CAROTID PULSE

MUSCLES OF THE NECK

STERNOCLEIDOMASTOIDFROM UPPER PART OF MANUBRIUM STERNI (STERNAL HEAD) AND MEDIAL THIRD OF THE CLAVICLE (CLAVICULAR HEAD) TO MASTOID PROCESSTILTING HEAD AND FACE UPWARDS AND TO THE

OPPOSITE SIDEACCESSORY NERVE (XII)

TRAPEZIUSFROM EOP AND SNL TO LATERAL 1/3 OF CLAVICLE,

ACROMIONSHOULDER SHRUGACCESSORY NERVE (XII)

STERNOCLEIDOMASTOID

TRAPEZIUS

TRAPEZIUS STERNOCLEIDOMASTOID

SUPRAHYOID MUSCLESDIGASTRIC, POSTERIOR BELLY

FROM MASTOID TO LESSER HORN OF THE HYOID

DIGASTRIC, ANTERIOR BELLY

INNER SURFACE OF MANDIBLE TO LESSER HORN OF THE HYOID

MYLOHYOID

FROM MYLOHYOID LINE TO ANTERIOR SURFACE OF THE HYOID

GENIOHYOID

FROM INFERIOR MENTAL SPINE TO BODY OF HYOID

SUPRAHYOID MUSCLES ALL ELEVATE THE HYOID

INFRAHYOID MUSCLESSTERNOHYOID

FROM STERNUM TO HYOIDSTERNOTHYROID

FROM STERNUM TO THE OBLIQUE LINE, THYROID CARTILAGE

THYROHYOIDFROM OBLIQUE LINE, THYROID CARTILAGE TO THE

HYOID BONEOMOHYOID

FROM SCAPULA TO THE HYOID BONE

ALL INFRAHYOID MUSCLES DEPRESS THE HYOID

NECK MUSCLES

SUPRAHYOID GROUP OF MUSCLES

INFRAHYOID GROUP OF MUSCLES

CERVICAL LYMPHATICS

• LEVEL 1 – Submental / Submandibular Lymph Nodes

• LEVEL 2 – Upper Jugular Lymph Nodes

• LEVEL 3 – Middle Jugular Lymph Nodes

• LEVEL 4 – Lower Jugular Lymph Nodes

• LEVEL 5 – Posterior Triangle Lymph Nodes

• LEVEL 6 – Anterior Compartment Lymph Nodes

6 LEVELS FOR DESCRIBING THE LOCATION OF LYMPH NODES IN THE NECK

SUBLEVEL DIVISION OF NECK LEVELS2001 Report of the American Head and Neck Society’s Neck

Dissection Committee

Per structure/region

• Neck – Integrated as “filtering stations”– Receive almost all parts of head and neck region – Left side, drains into junction of left subclavian and

internal jugular veins at the left thoracic duct– Right side, drains into junction of the right

subclavian and internal jugular veins at right thoracic duct

– Includes lymphatic organs of nasopharynx and oropharynx

– Normal nodes are neither visible nor palpable

Per structure/region

• Esophagus– Posterior mediastinum and pulmonary hilum

• Face and external nose– Mainly submandibular lymph nodes

• Nasal cavity– Retropharyngeal and deep cervical

Per structure/region

• Larynx – Subdivided anatomically into supraglottic, glottic,

and subglottic– More numerous above the glottis

• Supraglottic- deep cervical lymph nodes» Ipsilateral drainage complemented by

contralateral drainage• Glottic – sparse • Subglottic –deep cervical lymph nodes

» With connections to peritracheal and mediastinal nodes

» Ipsilateral and contralateral drainage

Per structure/region

• Lips– Submandibular and submental lymph nodes

• Tongue and oral floor– Ipsilateral and contralateral submandibular and

submental nodes which drain to lymph nodes at junction of the facial and internal jugular veins

• Parotid gland– Intraglandular and periglandular nodes to

submandibular and deep jugular nodal chains

Per structure/region

• Submandibular gland– Lymph nodes in the lateral and posteroinferior

portion of the gland

• Pharynx– Upper portion: retropharyngeal nodes– Lower portion: parapharyngeal or deep cervical

nodes

Lymphatic Drainage of External Areas of the Head and Neck

Lymphatic Drainage from Internal Areas of the Head and Neck

DRAINAGE PATTERNS1. SUBMENTAL – floor of the mouth, anterior oral

tongue, anterior mandibular ridge and lower lip

2. SUBMANDIBULAR – oral cavity, anterior nasal cavity, soft-tissue structures of the midface, submandibular gland

3. UPPER JUGULAR – oral cavity, nasal cavity, nasopharynx, hypopharynx, larynx, parotid gland

4. MIDDLE JUGULAR – oral cavity, nasopharynx, hypopharynx, oropharynx and larynx, cervical esophagus

DRAINAGE PATTERNS

6. POSTERIOR TRIANGLE GROUP – nasopharynx, oropharynx, cutaneous structures of the posterior scalp and neck

7. ANTERIOR COMPARTMENT – thyroid gland, glottic and subglottic larynx, apex of the pyriform sinus and cervical esophagus

WORK-UP OF ASYMMETRIC, UNILATERAL NODAL NECK MASS

1. COMPLETE REPEATED P.E. OF:

ORAL CAVITY, NASOPHARYNX, HYPOPHARYNX, LARYNX, THYROID, SALIVARY GLANDS, SKIN OF THE NECK

2. NEEDLE BIOPSY

3. IMAGING – CHEST, UPPER AERODIGESTIVE TRACT (+)

4. PANENDOSCOPY WITH GUIDED BIOPSY BASED ON LOCATION OF THE NODAL MASS –NASOPHARYNX, BASE OF THE TONGUE

5. OPEN BIOPSY OF THE CERVICAL MASS

NECK DISSECTION

THE END