Navigating the Neck:Landmarks and Danger Points

Dr. Elisabeth Ference and Dr. Jose DutraNovember 20, 2014

Northwestern Feinberg School of MedicineDepartment of Otolaryngology- Head and Neck Surgery

Overview

Locating cranial nerves VII, IX-XII

Important Anatomic Relationships: Carotid Artery, Erb’s Point, Thyrocervical Trunk

Neck Level INeck Level IIa&bNeck Level IVNeck Level V

Drawings from Netter and Photos from OR unless otherwise specified

VII (in the neck) Where are good places to identify the marginal branch of the facial nerve?

VII (in the neck) ~ 1 cm anterior and inferior to angle of mandible

At the mandibular notch Within the fascia of the submandibular gland (superficial level of deep cervical fascia)

Superficial to adventitia of the facial vein Facial vein can be divided where it crosses the posterior digastric and elevated to protect the nerve

Møller, M. N., & Sørensen, C. H. (2012)

IX

What muscle does the glossopharyngeal nerve travel with and innervate?

IX Leave the posterior fossa through the jugular foramen

Lies with the stylopharyngeus (which it innervates)

Muscle and nerve enter pharynx between the lower fibers of the superior pharyngeal constrictor and upper fibers of the middle constrictor

X: SLN At what level does the superior laryngeal nerve divide?

X: SLN Divides just posterior and inferior to the greater cornu of the hyoid External follows the superior thyroid artery on the inferior constrictor muscle until it enters the cricothyroid

Internal branch follows the superior laryngeal branch of the superior thyroid artery until it pierces the lateral thyrohyoid membrane

X: Cernea Classification for EBSLN (based on Superior Thyroid Artery)

Type 1: cross behind superior thyroid artery greater than 1 cm above the upper border of the thyroid gland 68%

Type 2a: cross within 1 cm of the upper border of the thyroid 11%

Type 2b: cross below the upper border of the gland 14%, Vulnerable to injury when ligating the superior thyroid vascular pedicle

Ozlugedik, S., Acar, H. I., Apaydin, N., Tekdemir, I., Elhan, A., & Comert, A. (2007).

X: Friedman Classification for EBSLN (Based on Inferior Constrictor)

Type 1, nerve running superficial to the IC (23%) At risk when ligate the superior thyroid pedicle

Type 2: penetrate the muscle 1 cm before reaching the cricothyroid muscle (68%)

Type 3: nerve runs deep into the IC (10%)

Ozlugedik, S., Acar, H. I., Apaydin, N., Tekdemir, I., Elhan, A., & Comert, A. (2007).

X: RLN

Killian-Jamieson Triangle: inferior thyroid artery, trachea, common carotid artery

Triplanar: inferior constrictor, esophagus, lateral wall trachea

X: Zuckerkandl Process

Mohebati, A., & Shaha, A. R. (2012).

X: Inferior Thyroid Artery

Mohebati, A., & Shaha, A. R. (2012).

XI

What characterizes shoulder syndrome from spinal accessory nerve paralysis?

XI

Shoulder syndrome: pain, stiffness, drooping, limited abduction and flexion, aberrant scapular rotation (scapular winging)

http://www.msdlatinamerica.com/ebooks/PracticalOrthopaedicSportsMedicineArthrocopy/sid169169.html

Examination for XI Injury Weak head turn Weak shoulder shrug (may be preserved based on levator function)

Weakness of shoulder abduction past 90 degrees Requires upward rotation of the scapula by the trapezius

Note: more distal injury may spare function to SCM

Trapezius derives varying levels of innervation directly from cervical roots so function may not be completely absent http://

nervesurgery.wustl.edu/so/CaseStudies/2011/110325-1/Pages/default.aspx

XI

Name 4 places to find XI:

XI Retract posterior belly of the digastric superiorly, where it crosses superficial to the IJV Anterior to lateral process of C1

~4cm below the mastoid tip where penetrates the deep portion of SCM

The posterior border of the SCM ~1-2 cm superior to Erb’s Point

At penetration into the trapezius Lloyd, S. (2007).

XI Where is XI relative to the IJV?

XI Vast majority cross superficial to the vein

<3% posterior to the vein

Rare cases pass through the vein

Hinsley, M. L., & Hartig, G. K. (2010).

XII

Where does the hypoglossal nerve cross the ECA?

XII

Hooks around the external carotid at the take off of the occipital artery (lateral to both ICA, and ECA)

Can be found at level just superior to greater horn of the hyoid bone

XII Course of the nerve

Exits skull via the hypoglossal canal

Lies deep to the IJV, ICA, IX, X, XI

Curves 90 degrees and passes between IJV and ICA, surrounded by ranine veins▪ Gives branch to Ansa

Runs superficial to ECA and just inferior to the digastric

Extends superiorly along the hyoglossus muscle and into the genioglossus to the tip of the tongue

XII

Landmarks: Carotid Arteries and the Nerves

What nerve is lateral to both the ICA and ECA?

What 2 nerves lie between the ICA and ECA?

CN XII is lateral to both ICA and ECA CN IX and pharyngeal portion of X lie between ICA and ECA

Landmarks: Carotid Arteries and the Nerves

Landmarks: Erb’s Point What nerve is demarcated by * ?

*

Lesser Occipital

Greater Auricular

Supraclavicular

c/o Dr. Vanison’s Anatomy Questions

Landmarks: Erb’s Point

c/o Dr. Vanison’s Anatomy Questions

Landmarks: Thyrocervical TrunkWhat arteries cross the phrenic nerve laterally?

Landmarks: Thyrocervical Trunk

Tranverse cervical and suprascapular arteries course laterally over the surface fo the phrenic nerves

Neck Levels

Wang, Y., Ow, T. J., & Myers, J. N. (2012).

Level I

What are the boundaries of Ia?Ib?

Level I

Wang, Y., Ow, T. J., & Myers, J. N. (2012).

Level I

What is the clinical significance of levels Ia and Ib (ie when do you dissect Ia)?

Level I Drainage patterns Ia: lower lip, floor of mouth, ventral tongue

Ib: all other oral cavity subsites

Wang, Y., Ow, T. J., & Myers, J. N. (2012).

Level I What is the order of important structures, from inferior to superior, that you find going under the mylohyoid when you lift up the submandibular gland?

123

4

Level I

1. Hypoglossal2. Extension of

the submandibular gland

3. Submandibular duct

4. Lingual Nerve and submandibular ganglion

123

4

Level II

What are the boundaries of II? What structure divides it into a and b?

Level I

Wang, Y., Ow, T. J., & Myers, J. N. (2012).

Level IIa&b

What is the clinical significance between IIa and IIb (ie when do you dissect IIB)?

Level IIa&b

IIB: oropharynx and nasopharynx drain to IIB Therefore should mobilize XI

Oral cavity, larynx and hypopharynx first drain to IIa prior to IIb May not be necessary to dissect IIb if IIa not involved

Level IIa&b

Where is the jugulodigastric lymph node?

Level IIa&b

Level II node where IJV crossed by the posterior belly of the digastric Normal size <= 1.5 cm Other neck nodes should be < 1 cm

Level IIa&b

Level IIa&b What is deep to the posterior belly of the digastric?

Level IIa&b Posterior belly of the digastric is superficial to the ECA, ICA, IJV, sympathetic chain, CN XI, and CN XII

These structures are anterior to transverse process of C1

Level III What are the the surgical versus radiographic landmarks for level III?

Level III Surgical: carotid bifurcation to the omohyoid

Radiologic: hyoid bone to inferior border of the cricoid

Wang, Y., Ow, T. J., & Myers, J. N. (2012).

Level IV Where is the thoracic duct located relative to the thyrocervical trunk and transverse cervical artery?

Level IV Thoracic Duct

Superficial to the vertebral artery/vein and thyrocervical trunk

Lies at medial border of anterior scalene left neck, just anterior to the phrenic nerve

Joins venous system at the left internal jugular and left subclavian vein intersection

Also lymphatic drainage into IJV-subclavian junction on right!

Thoracic Duct Injury Non-surgical options (low output < 500 mL/day) Low-fat diet w/ medium-chain triglycerides

TPN Careful monitoring fluid and electrolytes

Drainage of leakage Somatostatin analogs such as octreotide

Negative pressure wound therapy

Surgical Options (> 1L/day, persistant) Percutaneous lymphography-guided thoracic duct cannulation/embolization

Surgical repair Closure by locoregional flaps

VATS/thoracotomy/pleuro-desis/pleura-venous or pleura-peritoneal shunts

Level V

What are the boundaries of level V?

Level V Boundaries: SCM, trapezius, clavicle

Divided by omohyoid Occipital Triangle

Supraclavicular triangle

Wang, Y., Ow, T. J., & Myers, J. N. (2012).

Level V What is deep to the posterior belly of the omohyoid

Level V Brachial plexus

IJV Phrenic Transverse cervical vessels

Level IV and V

Level IV and V

Cervical Roots

Phrenic Nerve

Transverse Cervical Artery and

Vein

ReferencesBatstone, M. D., Scott, B., Lowe, D., & Rogers, S. N. (2009). Marginal mandibular nerve injury during neck dissection and its impact on patient perception of appearance. Head & Neck, 31(5), 673–8. doi:10.1002/hed.21013

Cernea, C. R., Ferraz, A. R., Nishio, S., Dutra, A., Hojaij, F. C., & dos Santos, L. R. (n.d.). Surgical anatomy of the external branch of the superior laryngeal nerve. Head & Neck, 14(5), 380–3. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/1399571

Friedman, M., LoSavio, P., & Ibrahim, H. (2002). Superior laryngeal nerve identification and preservation in thyroidectomy. Archives of Otolaryngology--Head & Neck Surgery, 128(3), 296–303. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11886347

Fujimura, I., de Souza, R. R., de Carvalho, C. A. F., & Rodrigues, A. J. (1990). A method for locating the marginal mandibular branch of the facial nerve in the neck. Clinical Anatomy, 3(2), 143–147. doi:10.1002/ca.980030207

Hinsley, M. L., & Hartig, G. K. (2010). Anatomic relationship between the spinal accessory nerve and internal jugular vein in the upper neck. Otolaryngology--Head and Neck Surgery : Official Journal of American Academy of Otolaryngology-Head and Neck Surgery, 143(2), 239–41. doi:10.1016/j.otohns.2010.03.033

Lloyd, S. (2007). Accessory nerve: anatomy and surgical identification. The Journal of Laryngology and Otology, 121(12), 1118–25. doi:10.1017/S0022215107000461

Mohebati, A., & Shaha, A. R. (2012). Anatomy of thyroid and parathyroid glands and neurovascular relations. Clinical Anatomy (New York, N.Y.), 25(1), 19–31. doi:10.1002/ca.21220

Møller, M. N., & Sørensen, C. H. (2012). Risk of marginal mandibular nerve injury in neck dissection. European Archives of Oto-Rhino-Laryngology : Official Journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : Affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery, 269(2), 601–5. doi:10.1007/s00405-011-1610-2

Ozlugedik, S., Acar, H. I., Apaydin, N., Tekdemir, I., Elhan, A., & Comert, A. (2007). Surgical anatomy of the external branch of the superior laryngeal nerve. Clinical Anatomy (New York, N.Y.), 20(4), 387–91. doi:10.1002/ca.20399

Robbins, K. T., Shaha, A. R., Medina, J. E., Califano, J. A., Wolf, G. T., Ferlito, A., … Day, T. A. (2008). Consensus statement on the classification and terminology of neck dissection. Archives of Otolaryngology--Head & Neck Surgery, 134(5), 536–8. doi:10.1001/archotol.134.5.536

Sheahan, P., & Murphy, M. S. (2011). Thyroid Tubercle of Zuckerkandl: importance in thyroid surgery. The Laryngoscope, 121(11), 2335–7. doi:10.1002/lary.22188

Shin, J., & Cunningham, M. (n.d.). Otolaryngology Prep and Practice. San Diege: Plural Publishing.Wang, Y., Ow, T. J., & Myers, J. N. (2012). Pathways for cervical metastasis in malignant neoplasms of the head and neck region. Clinical Anatomy (New York, N.Y.), 25(1), 54–71. doi:10.1002/ca.21249

Questions?