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3a. 3. The Triangles of the Neck
FIG. 512 - The triangles of the neck. The side of the neck presents a somewhat quadrilateral outline (Fig. 512), limited, above, by the lower border of the body of the mandible, and an imaginary line extending from the angle of the mandible to the mastoid process; below, by the upper border of the clavicle; in front, by the middle line of the neck; behind, by the anterior margin of the Trapezius. This space is subdivided into two large triangles by the Sternocleidomastoideus, which passes obliquely across the neck, from the sternum and clavicle below, to the mastoid process and occipital bone above. The triangular space in front of this muscle is called the anterior triangle; and that behind it, the posterior triangle. Anterior Triangle.—The anterior triangle is bounded, in front, by the middle line of the neck; behind, by the anterior margin of the Sternocleidomastoideus; its base, directed upward, is formed by the lower border of the body of the mandible, and a line extending from the angle of the mandible to the mastoid process; its apex is below, at the sternum. This space is subdivided into four smaller triangles by the Digastricus above, and the superior belly of the Omohyoideus below. These smaller triangles are named the inferior carotid, the superior carotid, the submaxillary, and the suprahyoid. The Inferior Carotid, or Muscular Triangle, is bounded, in front, by the median line of the neck from the hyoid bone to the sternum; behind, by the anterior margin of the Sternocleidomastoideus; above, by the superior belly of the Omohyoideus. It is covered by the integument, superficial fascia, Platysma, and deep fascia, ramifying in which are some of the branches of the supraclavicular nerves. Beneath these superficial structures are the Sternohyoideus and Sternothyreoideus, which, together with the anterior margin of the Sternocleidomastoideus, conceal the lower part of the common carotid artery. (*99 This vessel is enclosed within its sheath, together with the internal jugular vein and vagus nerve; the vein lies lateral to the artery on the right side of the neck, but overlaps it below on the left side; the nerve lies between the artery and vein, on a plane posterior to both. In front of the sheath are a few descending filaments from the ansa hypoglossi; behind the sheath are the inferior thyroid artery, the recurrent nerve, and the sympathetic trunk; and on its medial side, the esophagus, the trachea, the thyroid gland, and the lower part of the larynx. By cutting into the upper part of this space, and slightly displacing the Sternocleidomastoideus, the common carotid artery may be tied below the Omohyoideus. The Superior Carotid, or Carotid Triangle, is bounded, behind by the Sternocleidomastoideus; below, by the superior belly of the Omohyoideus; and above, by the Stylohyoideus and the posterior belly of the Digastricus. It is covered by the integument, superficial fascia, Platysma and deep fascia; ramifying in which are branches of the facial and cutaneous cervical nerves. Its floor is formed by parts of the Thyrohyoideus, Hyoglossus, and the Constrictores pharyngis medius and inferior. This space when dissected is seen to contain the upper part of the common carotid artery, which bifurcates opposite the upper border of the thyroid cartilage into the external and internal carotid. These vessels are somewhat concealed from view by the anterior margin of the Sternocleidomastoideus, which overlaps them. The external and internal carotids lie side by side, the external being the more anterior of the two. The following branches of the external carotid are also met with in this space: the superior thyroid, running forward and downward; the lingual, directly forward; the external maxillary, forward and upward; the occipital, backward; and the ascending pharyngeal, directly upward on the medial side of the internal carotid. The veins met with are: the internal jugular, which lies on the lateral side of the common and internal carotid arteries; and veins corresponding to the above-mentioned branches of the external carotid—viz., the superior thyroid, the lingual, common facial, ascending pharyngeal, and sometimes the occipital—all of which end in the internal jugular. The nerves in this space are the following. In front of the sheath of the common carotid is the ramus descendens hypoglossi. The hypoglossal nerve crosses both the internal and external carotids above, curving around the origin of the occipital artery. Within the sheath, between the artery and vein, and behind both, is the vagus nerve; behind the sheath, the sympathetic trunk. On the lateral side of the vessels, the accessory nerve runs for a short distance before it pierces the Sternocleidomastoideus; and on the medial side of the external carotid, just below the hyoid bone, may be seen the internal branch of the superior laryngeal nerve; and, still more inferiorly, the external branch of the same nerve. The upper portion of the larynx and lower portion of the pharynx are also found in the front part of this space. The Submaxillary or Digastric Triangle corresponds to the region of the neck immediately beneath the body of the mandible. It is bounded, above, by the lower border of the body of the mandible, and a line drawn from its angle to the mastoid process; below, by the posterior belly of the Digastricus and the Stylohyoideus; in front, by the anterior belly of the Digastricus. It is covered by the integument, superficial fascia, Platysma, and deep fascia, ramifying in which are branches of the facial nerve and ascending filaments of the cutaneous cervical nerve. Its floor is formed by the Mylohyoideus, Hyoglossus, and Constrictor pharyngis superior. It is divided into an anterior and a posterior part by the stylomandibular ligament. The anterior part contains the submaxillary gland, superficial to which is the anterior facial vein, while imbedded in the gland is the external maxillary artery and its glandular branches; beneath the gland, on the surface of the Mylohyoideus, are the submental artery and the mylohyoid artery and nerve. The posterior part of this triangle contains the external carotid artery, ascending deeply in the substance of the parotid gland; this vessel lies here in front of, and superficial to, the internal carotid, being crossed by the facial nerve, and gives off in its course the posterior auricular, superficial temporal, and internal maxillary branches: more deeply are the internal carotid, the internal jugular vein, and the vagus nerve, separated from the external carotid by the Styloglossus and Stylopharyngeus, and the glossopharyngeal nerve. (*100 The Suprahyoid Triangle is limited behind by the anterior belly of the Digastricus, in front by the middle line of the neck between the mandible and the hyoid bone; below, by the body of the hyoid bone; its floor is formed by the Mylohyoideus. It contains one or two lymph glands and some small veins; the latter unite to form the anterior jugular vein. Posterior Triangle.—The posterior triangle is bounded, in front, by the Sternocleidomastoideus; behind, by the anterior margin of the Trapezius; its base is formed by the middle third of the clavicle; its apex, by the occipital bone. The space is crossed, about 2.5 cm. above the clavicle, by the inferior belly of the Omohyoideus, which divides it into two triangles, an upper or occipital, and a lower or subclavian. The Occipital Triangle, the larger division of the posterior triangle, is bounded, in front, by the Sternocleidomastoideus; behind, by the Trapezius; below, by the Omohyoideus. Its floor is formed from above downward by the Splenius capitis, Levator scapulæ, and the Scaleni medius and posterior. It is covered by the skin, the superficial and deep fasciæ, and by the Platysma below. The accessory nerve is directed obliquely across the space from the Sternocleidomastoideus, which it pierces, to the under surface of the Trapezius; below, the supraclavicular nerves and the transverse cervical vessels and the upper part of the brachial plexus cross the space. A chain of lymph glands is also found running along the posterior border of the Sternocleidomastoideus, from the mastoid process to the root of the neck. The Subclavian Triangle, the smaller division of the posterior triangle, is bounded, above, by the inferior belly of the Omohyoideus; below, by the clavicle; its base is formed by the posterior border of the Sternocleidomastoideus. Its floor is formed by the first rib with the first digitation of the Serratus anterior. The size of the subclavian triangle varies with the extent of attachment of the clavicular portions of the Sternocleidomastoideus and Trapezius, and also with the height at which the Omohyoideus crosses the neck. Its height also varies according to the position of the arm, being diminished by raising the limb, on account of the ascent of the clavicle, and increased by drawing the arm downward, when that bone is depressed. This space is covered by the integument, the superficial and deep fasciæ and the Platysma, and crossed by the supraclavicular nerves. Just above the level of the clavicle, the third portion of the subclavian artery curves lateralward and downward from the lateral margin of the Scalenus anterior, across the first rib, to the axilla, and this is the situation most commonly chosen for ligaturing the vessel. Sometimes this vessel rises as high as 4 cm. above the clavicle; occasionally, it passes in front of the Scalenus anterior, or pierces the fibers of that muscle. The subclavian vein lies behind the clavicle, and is not usually seen in this space; but in some cases it rises as high as the artery, and has even been seen to pass with that vessel behind the Scalenus anterior. The brachial plexus of nerves lies above the artery, and in close contact with it. Passing transversely behind the clavicle are the transverse scapular vessels; and traversing its upper angle in the same direction, the transverse cervical artery and vein. The external jugular vein runs vertically downward behind the posterior border of the Sternocleidomastoideus, to terminate in the subclavian vein; it receives the transverse cervical and transverse scapular veins, which form a plexus in front of the artery, and occasionally a small vein which crosses the clavicle from the cephalic. The small nerve to the Subclavius also crosses this triangle about its middle, and some lymph glands are usually found in the space.
Note 99. Therefore the common carotid artery and internal jugular vein are not, strictly speaking, contained in this triangle, since they are covered by the Sternocleidomastoideus; that is to say, they lie under that muscle, which forms the posterior border of the triangle. But as they lie very close to the structures which are really contained in the triangle, and whose position it is essential to remember in operating on this part of the artery, it is expedient to study the relations of all these parts together. [back] Note 100. The remark made about the inferior carotid triangle applies also to this one. The structures enumerated as contained in its posterior part lie, strictly speaking, beneath the muscles which form the posterior boundary of the triangle; but as it is very important to bear in mind their close relation to the parotid gland, all these parts are spoken of together. [back]
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