Neck borders. The neck is delimited from the head by a line running along the lower edge of the lower jaw, the apex of the mastoid process, the superior nuchal line, and the external occipital protuberance.

From the chest, upper limb and back to the neck delimit the jugular notch of the sternum, the clavicle and the line drawn from the acromial process of the scapula to the spinous process of the UP of the cervical vertebra.

There are four regions on the neck: anterior, sternocleidomastoid, lateral and posterior.

Borders of the neck areas carried out along external landmarks: the lower edge of the lower jaw, along the anterior and posterior edges of the sternocleidomastoid muscle, the anterior edge of the trapezius muscle, jugular notch of the sternum and clavicle (Fig. 6.1).

Anterior region of the neck. Projections of the muscles on the neck.

Anterior neck area limited from above by the lower edge of the lower jaw and chin, from below - by the jugular notch of the sternum, on the sides - by the medial (anterior) edges of m. sternocleidomas toideus. Within the anterior region, with the help of a palpable hyoid bone, the suprahyoid part, pars suprahyoidea, and the subhyoid part, pars infrahyoidea, are isolated. In each of them, in turn, several triangles of the neck are distinguished, which are built with the help of projections of two more muscles: digastric and scapular-hyoid.

The anterior belly of the digastric muscle is projected from the middle of the lower edge of the chin to the lateral surface of the hyoid bone; posterior - from the hyoid bone to the mastoid process of the temporal bone. Projection m. digastricus makes it possible to distinguish two triangles in the suprahyoid part of the neck: submandibular (paired) and submental (unpaired).

Topographically and anatomically, four areas are distinguished on the neck: anterior, sternocleidomastoid, lateral and posterior [outer]. Within these areas, a number of muscle triangles are distinguished, which are important landmarks in surgical interventions on the organs of the neck.

Neck areas

Front neck, regio cerviccalis anterior - has the form of a triangle, the base of which is turned upwards. This area is limited: from above - by the base of the lower jaw; from below - by the jugular notch of the sternum, and on the sides - by the front edges of the right and left sternocleidomastoid muscles. The anterior midline divides this region of the neck into the right and left medial triangles of the neck.
sternocleidomastoid region, regio stemocleidomastoidea - extends in the form of a strip from the mastoid process (above and behind) to the sternal end of the clavicle (below and in front).
Lateral region of the neck, regio cervicis lateralis - has the form of a triangle, the most acute angle of which is turned upwards. This area is located between the posterior edge of the sternocleidomastoid muscle in front and the lateral edge of the trapezius muscle behind, bounded from below by the clavicle.
Back of the neck[vynaya area], regio cervicis posterior - on the sides is limited by the lateral edges of the trapezius muscles; from above - the upper vynyny line; below - a transverse line connecting the right and left acromion and passes through the spinous process VII. The posterior midline divides this region of the neck into right and left parts.

Neck Triangles

The median line, which is drawn from the chin to the jugular notch, divides the anterior region of the neck into the right and left parts, in which the anterior cervical triangle and the posterior cervical triangle are distinguished.
Anterior cervical triangle, trigonum colli anterius - paired, located in the front of the neck. It is limited by the lower edge of the lower jaw, the front edge of m. sternocleidomastoideus and the median line of the neck. Upper abdomen m. omohyoideus divides it into several smaller triangles.
1. sleepy triangle, trigonum caroticum - limited by the hind belly m. digastricus and upper abdomen m. omohyoideus and the leading edge of m. sternocleidomastoideus. The joint carotid artery passes through it, which here is subdivided into the external and internal carotid arteries, as well as the internal jugular vein and the vagus nerve. Within this triangle, the external carotid artery is ligated to prevent bleeding during surgical interventions on the face and tongue (B. V. Ognev, V. X. Frauchi, I960).
2. Scapular-tracheal triangle, trigonum omotracheale - limited to the upper abdomen m. omohyoideus, anterior-lower edge m. sternocleidomastoideus and the median line of the neck. Within this triangle are vital organs: the carotid artery and the jugular vein. Surgical interventions are carried out here (tracheotomy, strumectomy, laryngectomy, ligation of the common carotid artery and internal jugular vein).
3. Submandibular triangle, trigonum submandibular (fossa submandibularis) - limited by the anterior and posterior abdomen m. digastricus and the lower edge of the lower jaw. It contains the submandibular salivary glands and the facial artery and vein, lingual and hypoglossal nerves. Within this triangle, incisions are made for phlegmon of the floor of the mouth, the submandibular salivary glands are removed for neoplasms and the lymph nodes are extirpated for cancer of the tongue and lips (B. V. Ognev, V. X. Frauchi, 1960).
4. Pirogov triangle, trigonum Pirogowi (language triangle, trigonum linguale) - located in the submandibular triangle. It is limited: from below - by a tendon (posterior abdomen), m. digastricus, front - rear edge m. mylohyoideus; from above - a segment of the hypoglossal nerve. Within its limits, a lingual vein and an artery are designed, which must be taken into account in clinical practice. Access to the lingual artery is carried out in this triangle by cutting the fibers of the hyoid-lingual muscle, which are directed obliquely longitudinally.
Posterior cervical triangle, trigonum cervicale posterius - paired, located between the posterior edge of m. stemocleidomastoideus and the anterior edge of the trapezius muscle and clavicle. The lower belly of the scapular-hyoid muscle divides it into smaller triangles.
1. Scapular-clavicular triangle, trigonum omoclaviculare - formed: in front - by the posterior edge of m. sternocleidomastoideus-, from below - by the collarbone; behind - the lower abdomen m. omohyoideus. It passes: the external jugular vein, suprascapular artery and vein, on the left - the thoracic duct, and on the right - the right lymphatic duct. In this triangle, supraclavicular ligation of the subclavian artery and vein is performed, as well as anesthesia of the brachial plexus during operations on the upper limb (B. V. Ognev, V. X. Frauchi, 1960).
2. Scapular-trapezoid triangle, trigonum omotrapezoideum, - limited: behind - m. trapezius; front - back edge m. sternocleidomastoideus; from below - the lower belly m. omohyoideus. It contains: the subclavian artery and its branches, the superficial cervical artery and the transverse artery of the neck, accessory nerve, n. accessorius, three long bundles and short branches of the brachial plexus and cutaneous branches of the cervical plexus.
3. Extramaxillary fossa, fossa retromandibular - limited: behind - by the mastoid process and m. sternocleidomastoideus; from above - by the external auditory canal, in front - by the posterior edge of the ramus mandibulae; near the middle - the styloid process and the muscles that originate from it (mm. stylohyoideus, styloglossus, stylopharyngeus). The retromaxillary fossa is filled with the posterior part of the parotid gland, the facial and ear-temporal nerve, the external carotid artery and the maxillary vein, v. retromandibular. On the neck between the scalene muscles there are two triangular spaces: interscalene and prescalene:
1) Interstitial space, spatium interscalenum - limited by the anterior and middle scalene muscle, and from below - by the II rib. It contains the subclavian artery and the brachial plexus;
2) Pereglacial space, spatium antesc.alenum - located between the anterior scalene muscle at the back and the sternothyroid and sternohyoid muscles at the front. It contains: the subclavian vein, the suprascapular artery and the phrenic nerve.

CHAPTERVI.

Borders:

The upper border of the neck runs from the chin along the margo inferior mandibulae and its ascending branch to the external auditory meatus; further, the border line follows under the mastoid process, ascends upward to the superior nuchal line, linea nuchae superior, goes medially and meets a similar line of the opposite side on the protuberantia occipitalis externa along the midline.

The lower border starts from the handle of the sternum, manubrium sterni, runs along the collarbone to the acromial process of the scapula and then goes to the spinous process of the VII cervical vertebra.

The human neck is divided into the anterior region, regio colli anterior, and the posterior region, regio colli posterior.

The main vital organs lie in the anterior region of the neck (Fig. 58); the posterior region is represented predominantly by muscles. In the anterior region of the neck, surgical interventions are performed more often than in the posterior region.

FRONT REGION OF THE NECK.

The anterior neck is divided by the hyoid bone into two large regions: the suprahyoid region, regio suprahyoidea, and the infrahyoid region, regio infrahyoidea.

Each of these areas is divided into several triangles that are important when performing surgical interventions on the neck (Fig. 59.)

Suprahyoid region

It has the shape of a triangle and is limited by the lower edge of the lower jaw; the base of the triangle is the hyoid bone. This triangle is made up of three triangles:

Trigonum submaxillare - submandibular triangle

Paired triangle, limited: in front - venter anterior m. digastrici, behind - venter posterior m. digastrici, above - margo inferior mandibulae.

In the submandibular triangles, the following are performed: 1) extirpation of the submandibular lymph nodes in case of cancer of the lip and tongue; 2) removal of the submandibular salivary glands in neoplasms; 3) incisions for phlegmon of the floor of the mouth (for example, with Ludovik's angina); 4) dressing a. lingualis in the Pirogov triangle as a preliminary operation before removing the tongue.

Rice. 58. Anterior region of the neck.

1-n. accessorius; 2 - V. jugulans externa; 3-a. carotis externa; 4-a. carotis interna; 5 - m. stylohyoideus; 6-gl. submaxillaris; 7 - m. digastricus; 8 - m. mylohyoideus; 9-n. hypoglossus; 10-a. thyreoidea superior; 11-v. jugulans interna; 12 - m. omohyoideus.

Trigonum Pirogovi - Pirogov's triangle - is within the submandibular triangles and is limited: in front - by the posterior edge of m. mylohyoideus; above - arcus n. hypoglossi; below - intermediate tendon stretch m. digastricus. The bottom of the triangle is formed by m. hyoglossus. A. lingualis is found between the fibers of m. hyoglossus and deeper m. constrictor pharyngis medius. Behind the middle constrictor of the pharynx is the mucous membrane of the pharyngeal cavity. Therefore, when searching for an artery, great care is required, since it is possible, having broken through the mucous membrane, to penetrate into the pharyngeal cavity and infect the surgical field from the mucous membrane.

It should be remembered that v. lingualis does not lie with the artery, but is located more superficially - on the outer side of m. hyoglossus, and along with it lies the lingual nerve, n. lingualis.

Trigonum submentale - submental triangle

Unpaired triangle, it is limited laterally - by the anterior bellies of the digastric muscles; behind - the hyoid bone.

Within the triangle, the following are made: 1) incisions for phlegmon of the bottom of the mouth in order to drain pus; 2) concomitant removal of the submental lymph nodes, 1-di mentales, with the extirpation of the submandibular lymph nodes due to a malignant tumor of the tongue or lip.

Rice. 59. Triangles of the neck (scheme).

A. Suprahyoid region: 1 - submandibular triangle; 2 - Pirogovsky triangle; 3 - chin triangle. B. Sublingual region: 1-sleepy triangle; 2 - hyoid tracheal triangle; 3 - sublingual triangle; 4 - sublingual trapezoid triangle.

retromaxillary fossa,fossaretromandibularis.

It represents an oval-shaped depression located behind the ascending branch of the lower jaw.

Its borders: in front - the ascending branch of the lower jaw, ramus ascendens mandibulae; behind - the mastoid process, processus mastoideus, from above - the external auditory meatus, meatus acusticus externus; below - the posterior belly of the digastric muscle, venter posterior m. digastrici. The bottom of this depression is the styloid process with the so-called "anatomical bouquet of muscles", represented by three muscles. All of them start from the styloid process, processus styloideus, and are called at the place of attachment: m. Stylohyoideus - awl-hyoid muscle, m. styloglossus - awl-lingual muscle and m. stylopharyngeus - stylo-pharyngeal muscle.

Within the posterior jaw fossa are:

1. Glandula parotis - the parotid gland - with the dense parotid-masticatory fascia surrounding it, fascia parotideomasseterica.

2. A. carotis externa - external carotid artery - ascends along the edge of the ascending branch of the lower jaw. Dividing it by a. temporalis superficialis and a. maxillaris interna is carried out at the level of the neck of the articular process of the lower jaw.

3. V. jugularis externa - external jugular vein - is formed behind the auricle from the confluence of two veins - v. Jugularis externa posterior and v. occipitalis, somewhat lower, within the posterior maxillary fossa, the external jugular vein connects with v. facialis posterior.

4. A. auricularis posterior - the posterior auricular artery - a branch of the external carotid artery, is separated from the main trunk within the retromaxillary fossa.

5. N. facialis - the facial nerve - upon exiting the foramen stylomastoideum, it immediately enters the thickness of the parotid gland.

6. N. auriculotemporalis - ear-temporal nerve, - separated from n. mandibularis, passes from the posterior mandibular fossa to the temporal region, where it accompanies the superficial temporal artery.

SUBlingual area

The median line sublingual region is divided into two symmetrical halves. Each half has the shape of a quadrilateral, the sides of which are the trachea, clavicle, m. trapezius, hyoid bone. Each quadrilateral is subdivided into four triangles. These triangles are built by crossing two muscles: m. sternocleidomastoideus and m. omohyoideus. Thus, in each of the four triangles, two sides are formed by m. sternocleidomastoideus and m. omohyoideus; the third side for each triangle will be one of the sides of the quadrilateral, so:

1. Trigonumomoclaviculare- scapular-clavicular triangle.

Limited: front - rear edge m. sternocleidomastoidei. back-front edge of venter inferior m. omohyoidei; below - the clavicle;

This triangle contains a number of important organs, which are often the object of surgical interventions. Produced here:

1) Supraclavicular ligation of the subclavian artery or vein of the same name. Operation gives high mortality owing to insufficient development of roundabout blood circulation.

2) Dissection, alcoholization and twisting of the phrenic nerve, located on the anterior surface of the anterior scalene muscle, m. scalenus anterior. These interventions are performed for cavernous pulmonary tuberculosis.

It must be remembered that n. phrenicus lies in the thickness of the fascia enveloping it. At the moment of release of the phrenic nerve during phrenicotomy or phrenic exeresis, when pulling the fascia with a hook to the side, the nerve trunk can also be entrained, since the fascia envelops the nerve from all sides. To prevent this, vertical incisions are made in the fascia on the sides of the nerve, after which the nerve is easily released.

3) Anesthesia of the brachial plexus according to the Kulenkampf method is performed during operations on the upper limb. For this purpose, a needle is inserted with a vertical injection on one transverse finger above the middle of the clavicle until pain appears, which indicates that the tip of the needle has penetrated to the primary bundles of the brachial plexus. After pulling the needle 0.5-1 cm back, novocaine solution is injected. After 20 minutes, the operation is performed. Anesthesia covers the entire upper limb, with the exception of the outer and inner parts of the shoulder. These departments receive additional branches from n. supraclavicularis posterior from the cervical plexus and from nn. intercostobrachiales. Therefore, for complete anesthesia, it is necessary to turn off these nerves that pass through the collarbone in its outer section and in the armpit.

In the area of ​​\u200b\u200bthis triangle, v passes superficially in the vertical direction. jugularis externa, below flowing into angulus venosus juguli, and subcutaneous supraclavicular nerves nn. supraclaviculares anterior, medius et posterior. Deeper in the triangle lies the prescalene fissure, spatium antescalenum, in which n passes vertically. phrenicus, lying on the front surface of the pa. scalenus anterior, and horizontally - v. subclavia. Even deeper is the interstitial gap, spatium interscalenum, through which passes below a. subclavia, and above it are the primary fasciculi of the brachial plexus. 4) Ligation of the thoracic duct for lymphorrhea. For this purpose, a venous jugular angle, angulus venosus juguli, m. sternocleidomastoideus in the lower section is pulled inward and gradually, pushing the fiber apart, the desired angle is found. v flows into it. jugularis externa, v. vertebralis, emerging from the depths and flowing into the posterior surface of the angle, and ductus thoracicus. The latter, being colorless, is poorly visible during the operation. Therefore, they usually resort to chipping all the fiber surrounding the venous angle; at the same time, the thoracic duct is also captured in the ligature, as judged by the cessation of the outflow of lymph. After eating, the duct is clearly visible, as it is filled with a white chylous mass.

There is another triangle in trigonum omoclaviculare.

Rice. 60. Ladder-vertebral triangle.

1-v. anonyma sinistra; 2 - trachea; 3 - esophagus; 4-a. carotis communis and n. vagus; 5-n. phrenicus and m. scalenus anterior; 6-a. vertebralis; 7-v. vertebralis; 8 - ductus thoracicus; 9-v. jugularis interna; 10-v. subclavia sinistra

Trigonumscale-overtebrale- stair-vertebral triangle.

It refers to the deep formations of the neck. Its boundaries (Fig. 60): medial - cervical spine; laterally - m. scalenus anterior; below - arcuate going a. subclavia.

This triangle is directed downwards with its base. At the top, the stair-vertebral triangle forms the angle of the same name, angulus scalenovertebralis. The apex of this angle lies on the anterior tubercle of the transverse process of the VI cervical vertebra - on the so-called carotid tubercle of Chassegnac.

Within the triangle lie the following formations:

1) A. vertebralis - the vertebral artery - departs at a right angle from the subclavian artery, ascends and enters the foramen transversarium of the transverse process of the VI cervical vertebra. In front, the subclavian artery is covered by the vein of the same name, v. subclavia.

2) Pars cervicalis trunci sympathici - the cervical part of the border cervical trunk - together with the middle intermediate and lower cervical ganglia, ganglion cervicale medium, intermedium et inferius.

3) A. thyreoidea inferior - the lower thyroid artery - is located above the vertebral artery, within the triangle it goes up, makes a bend to the medial side and, upon exiting the triangle, crosses the main neurovascular bundle of the neck behind it from the outside.

The syntopy of the elements contained in the stair-vertebral triangle is as follows: truncus sympathicus is located medially and deepest of all; laterally and more superficially lies a. vertebralis with the vein of the same name covering it. These formations are covered in front by the main neurovascular bundle of the neck, and a. carotis communis lies lateral to the sympathetic border trunk.

Within the triangle, a novocaine blockade of the lower cervical region of the borderline sympathetic trunk can be performed, for example, with angina pectoris, in order to turn off the accelerating fibers, rami accelerantes, which are part of n. cardiacus medius (branch ganglion cervicale medium).

Rice. 61. Deep muscles of the neck and interstitial fissures.

1 - m. longus capitis; 2 - m. scalenus anterior; 3 - m. scalenus medius; 4 - m. longus colli; 5 - spatium interscalenum; 6 - spatium antescalenum.

Topography of the interscalene and prescalene cracks.

The interstitial space, spatium interscalenum, is located within the trigonum omoclaviculare. It is a triangular slit with boundaries (Fig. 61); front and medial - m. scalenus anterior; behind and laterally - m. scalenus medius; below - I rib.

This gap gradually widens downward. It is of great practical importance, since a passes through it. subclavia and plexus brachialis. At the same time, below, adjacent to the 1st rib, the subclavian artery is located, above it are the primary fascicules of the brachial plexus.

On the 1st rib next to sulcus a. subclaviae there is a ladder or lisfranc tubercle, tuberculum scaleni (Lisfranci). In case of arterial bleeding from the arteries of the upper limb, the subclavian artery can be pressed against it to temporarily stop the bleeding.

Rice. 62. Lateral region of the neck.

The primary bundles of the brachial plexus are located one above the other and below touch the subclavian artery.

When ligating the subclavian artery in its third segment, m. That is, in the supraclavicular fossa, after the exit of the vessel from the interstitial fissure, it is necessary to carefully differentiate the elements of the neurovascular bundle, since there are known cases of erroneous ligation instead of the artery of one of the bundles. Checking the pulsation of the artery, used at this moment by the surgeon, can mislead him, since when a finger is placed on the fascicle, its transmission pulsation can be felt, emanating and transmitted from the artery.

The prescalene space, spatium antescalenum, is located anterior to the interstitial space. It is a gap located anterior to m. scalenus anterior and bounded behind by this muscle, and in front by m. sternocleidomastoideus, which is enclosed in the fascial sheath of the first own fascia of the neck.

In the preglacial fissure pass:

1) V. subclavia - subclavian vein, which lies in the transverse direction and crosses in front of m. scalenus anterior.

2) N. Phrenicus - phrenic nerve - goes vertically down the anterior surface of m. scalenus anterior (Fig. 62).

2. Trigonum omohyoideum s. caroticum-scapular- sublingualorsleepytriangle

Limited: front - venter superior m. omohyoidei; behind - the front edge m. sternocleidomastoidei; above - venter posterior m. digastrici.

Within the triangle lies the common carotid artery, a. carotis communis, which is divided at the level of the upper edge of the thyroid cartilage into a. carotis externa and interna.

Outside of the artery lies the internal jugular vein, v. jugularis interna, between the vessels behind - n.vagus, and on the anterior surface of the external carotid artery and below, on the anterior surface of the common carotid artery, lies ramus descendens n. hypoglossy. On the anterolateral surface of the jugular vein is truncus lymphaticus jugularis.

In the described triangle, all three carotid vessels are ligated when they are injured, or only the external carotid as a preliminary stage to prevent bleeding during operations on the face or tongue, as well as ligation of the internal jugular vein. The greatest danger of colliquat necrosis of the brain is created when the internal carotid artery is ligated. Somewhat better results are obtained by ligation of the common carotid artery. This is due to the development of roundabout blood circulation through the system of thyroid arteries (Fig. 63). Ligation of the external carotid artery is safe. The experience of the Great Patriotic War showed that even bilateral ligation of the external carotid arteries does not cause significant nutritional disorders of the soft tissues of the face.

3. Trigonum omotracheale -scapular- trachealtriangle

It is limited from the upper outer side by the inner edge, m. omohyoideus; from the lower outer - m. sternocleidomastoideus; from the inside - by the median line of the neck or trachea.

Rice. 63. roundaboutvesselsthyroidglands.

Within the triangle lies a number of vital organs: the larynx, trachea, carotid artery, jugular vein, thyroid gland. Therefore, within the triangle, operations are performed:

1) Laryngectomia - total removal of the larynx or hemilaryngectomia - removal of one half of the larynx - is performed for a malignant tumor of the larynx.

2) Laryngofissura - dissection of the larynx in order to remove a foreign body or a benign tumor.

3) Conicotomia - dissection lig. conicum s. lig. cricothyreoideum for the introduction of a tracheotomy cannula - an operation that replaces a tracheotomy. It is used in especially emergency cases, since technically it is simpler than tracheotomy: the larynx lies superficially and the reference points - the thyroid and cricoid cartilages - are well palpable. The disadvantage is the poor regeneration of the ligament after its intersection - its tears when the head is tilted back.

4) Tracheotomia (superior, inferior, media et lateralis) - upper, middle, lower and lateral tracheotomy, determined in relation to the isthmus of the thyroid gland. If the incision of two rings is made above the isthmus of the thyroid gland, the tracheotomy is called upper, if below the isthmus - lower; if at the same time the isthmus of the thyroid gland is crossed - middle, and if on the lateral surface of the trachea - lateral.

5) Hemi- and strumectomy - removal of one lobe or the entire thyroid gland. The first is produced with Graves' disease or with one form or another of goiter; with a malignant tumor of the gland, struma maligna, a total extirpation of the gland is performed along with the parathyroid glands within healthy tissues.

6) Ligatura a. carotidis communis - ligation of the common carotid artery (and internal jugular vein); at the same time, carotid vessels are searched for along the corresponding projection line (see below).

4. Trigonumomotrapezoideum- scapular-trapezoidtriangle

Limited from the upper inner side by the rear edge m. sternocleidomastoideus; from the lower inner side - venter inferior m. omohyoidei; behind - the front edge of the trapezius muscle, m. trapezius.

In this triangle are produced:

1) Vagosympathetic blockade as a preliminary stage before surgery on the organs of the chest cavity in order to prevent the development of pleuropulmonary shock. The injection of a needle for the introduction of a solution of novocaine to the vagus nerve and the sympathetic marginal cervical trunk, truncus sympathicus, is made behind the sternocleidomastoid muscle in its middle section to the spine. In this case, the anesthetic solution imbibes the fascial sheath of the main neurovascular bundle of the neck, as well as the prevertebral fascia adjacent to it from behind, together with the sympathetic trunk lying in it. It should be remembered that n. vagus lies outwards (in the posterior arteriovenous groove), and truncus sympathicus inwards from it - in the thickness of the fascia praevertebralis.

2) Anesthesia plexus cervicalis - anesthesia of the branches of the cervical plexus. Behind the middle m. sternocleidomastoideus, at approximately one point, the main skin branches of the plexus emerge from the inside to the subcutaneous tissue: n. auricularis magnus, going up to the area of ​​the outer ear and mastoid process, nn. supraclaviculares anterior, medius et posterior - go down through the collarbone within the subclavian region, n. occipitalis minor - back and up to the occipital region and n. cutaneus transversus colli - in the transverse direction to the midline of the neck. A vertical injection behind the sternocleidomastoid muscle blocks the entire bundle of cutaneous cervical nerves listed.

3) Oesophagotomia externa - an external section of the esophagus - is performed to extract foreign bodies or remove various tumors of its cervical part. For this purpose, an oblique incision behind the left sternocleidomastoid muscle with pulling it forward exposes the cervical part of the esophagus, which I dissect.

4) Incisiones - incisions - with deep phlegmon of the neck resulting from injury or perforation of the esophageal wall by a foreign body and m. P.

FASTIA OF THE NECK AND THEIR CLINICAL SIGNIFICANCE.

On the neck there are several fascia of different origin. Here, connective tissue and myogenic fascia are distinguished. The former are derivatives of the connective tissue, the latter phylogenetically underwent successive changes and gradually turned from flat muscles into fascial plates. An example of such a fascia is the middle fascia of the neck, fascia colli media (the second own fascia of the neck), which owes its origin to the clavicular-hyoid muscle, m. cleidohyoideus found in many mammals.

There are the following fasciae of the neck (Fig. 64):

1. Fascia superficialis - superficial fascia in the form of a thin cover surrounds the neck, being deeper than the subcutaneous fat. In the anterior section, this fascia is stratified into two plates, between which the subcutaneous muscle of the neck, m. subcutaneus collis. platysma myoides. This fascia in the region of the chest wall passes into the superficial fascia of the chest.

2. Fascia colli propria - the first own fascia of the neck - somewhat thicker than the previous one. It covers in the anterior part of the neck in the form of a cover m. sternocleidomastoideus, and in the posterior section - m. trapezius. In addition, on the sides, it gives off frontally extending processes that separate the anterior part of the neck from the posterior one.

Own fascia of the neck is a continuation of the parotid-chewing fascia, fascia parotideomasseterica. Going down and covering, as indicated, m. sternocleidomastoideus, this fascia is attached to the anterior edge of the sternum and collarbone. Behind, it is attached to the posterior edges of the shoulder blades, and along the midline it becomes thinner and gradually disappears in the back. In the upper section, it covers the submandibular salivary glands.

3. Fascia colli media - the middle fascia of the neck (the second own fascia of the neck) - starts from the inner surface of the edge of the lower jaw and, going down, is attached to the hyoid bone on the way and ends at the bottom at the inner edge of the sternum and clavicle. In its upper section to the hyoid bone, this fascia is of connective tissue origin, in the lower, as was said, it is a derivative of a reduced muscle. On its way, this fascia covers a number of anterior muscles of the neck in the form of covers: m. sternohyoideus, m. sternohyoideus, m. thyreohyoideus and m. omohyoideus.

All organs of the neck are shrouded in fascial covers, which are derivatives of the second own fascia of the neck or middle.

Rice. 64. Fascia of the neck.

1 - superficial fascia of the neck; 2 - the first own fascia of the neck; 3 - the second own fascia of the neck.

4. Fascia praevertebralis - prevertebral fascia (the third own fascia of the neck) - begins in the region of the tuberculum pharyngeum of the occipital bone and in the form of a rather thick frontal plate with an abundant amount of loose connective tissue descends and goes into the posterior mediastinum, where it gradually becomes thinner and is lost at level IV thoracic vertebra. On the way, this fascia gives off processes that cover the scalene muscles in the form of covers.

The clinical significance of the fascia of the neck is extremely high. Depending on which fascia is located between the purulent infiltrate, the clinical picture will be completely different.

Schematically, one can imagine the spread of pus in the interfascial spaces of the neck as follows.

1) If a purulent infection as a result of a wound or by a hematogenous or lymphogenous route penetrates between the sheets of the superficial fascia, sometimes going down between the sheets of the fascia, it can reach the mammary gland and cause secondary mastitis. This is explained by the fact that, passing to the chest wall, both sheets of the superficial fascia cover the mammary gland in front and behind, causing its mobility.

2) If the pus is deeper, in the slit-like space between the superficial and proper fascia of the neck, then it (although rarely) can go down this interfascial space and reach the posterior surface of the mammary gland. In these cases, there may be an abscess behind the gland.

3) If the infection is even deeper - in the thickness of the first own fascia of the neck, then the pus can concentrate in the cover m. sternocleidomastoideus, causing edema and inflammation limited to the limits of this muscle with its sausage-like swelling. Most often, the penetration of infection into this sheath comes from the terminal cell of the mastoid process, cellula terminalis processus mastoidei, with the so-called Bezold's form of mastoiditis.

4) If a purulent infection penetrates even deeper and is concentrated between the sheets of the first own and middle fascia of the neck, then the pus is localized in the supraclavicular and supraclavicular interaponeurotic spaces of the neck, spatium interaponeuroticum suprasternale et supraclaviculare. This is due to the fact that fascia colli propria is attached to the anterior edge, and fascia colli media is attached to the posterior edge of the sternum and clavicle. A large amount of fatty tissue lies in this space, due to which the inflammatory process proceeds quite rapidly. Clinically, this is manifested by the so-called "inflammatory collar", m. e. the presence of a demarcation line of inflammation: above this line, redness and swelling of the skin is observed; below - the color of the skin is normal, its inflammation is not observed.

5) If the purulent infection penetrates even deeper, m. e. beyond the middle fascia of the neck, then it can freely spread along the interfascial space down into the anterior mediastinum and cause anterior mediastinitis, mediastinitis anterior.

It should be emphasized that the fascial sheet lying on the anterior surface of the trachea is called fascia praetrachealis - pretracheal fascia, which is important during the tracheotomy operation. If this fascia is not sutured to the skin in the form of a labial fistula during surgery, then subcutaneous emphysema may occur, and in severe cases, emphysema of the anterior mediastinum. This is due to the fact that air penetrates between the tracheotomy cannula and soft surrounding tissues and is injected either into the subcutaneous tissue, or down to the anterior mediastinum.

6) If, due to injury to the esophagus or perforation of its wall by a foreign body, the infection penetrates into the periesophageal space, m. e. in the spatium retroviscerale, then it can freely descend into the posterior mediastinum and cause posterior mediastinitis, mediastinitis posterior.

INTERFASCIAL SPACES OF THE NECK

There are five main interfascial spaces of the neck.

1. Spatium interaponeuroticum suprasternale et supraclaviculare - the supraclavicular and supraclavicular interaponeurotic space - is a narrow gap at the top, gradually expanding downward. When considering this gap from the side, its triangular shape is noticeable. It contains a large amount of fatty tissue, reaching its greatest thickness directly above the sternum and collarbone, as well as a venous network of vessels. In the presence of pus in this space, as we have already said, an "inflammatory collar" is observed.

2. Saccus hyomandibularis - the sublingual-maxillary sac - is a well-defined dense fascial isolated pocket or sac in which the submandibular salivary gland is enclosed.

3. Spatium praeviscerale - pre-organ space - enclosed between fascia colli media and fascia praetrachealis. This slit-like cavity runs in the frontal plane and is the boundary between the soft tissues of the neck and the cavity of the neck, cavum colli. Below, it freely communicates with the anterior mediastinum. With deep phlegmon of this pre-organ space, the infection along the connective tissue can freely descend into the anterior mediastinum with the development of anterior mediastinitis.

4. Spatium retroviscerale - the posterior organ space - is a frontal gap between the posterior surface of the esophagus, as well as the fascial sheaths of the neurovascular bundles of the neck, located in front, and limited in the back by the prevertebral fascia, fascia praevertebralis. This space freely communicates with the posterior mediastinum (hence the posterior mediastinitis).

5. Spatium vasonervorum - the space of the neurovascular bundle - is a powerful multi-layered fascial sheath with a large amount of loose connective tissue. It envelops the main neurovascular bundle of the neck - the carotid artery, internal jugular vein, vagus nerve and other formations.

The last three spaces are enclosed in the cavity of the neck - cavum colli, which is limited in front of the second own (middle), and behind the third own (prevertebral) fascia of the neck.

All of these organs are firmly held by the fascial apparatus that wraps around them. When isolating each of them, many connective tissue bundles have to be crossed before individual elements of the neurovascular bundle can be isolated.

SURFACE VESSELS.

Superficial arterial vessels on the neck are represented only by very small branches and do not require a special description.

The superficial veins of the neck include:

1. V. jugularis externa - external jugular vein - goes in a vertical direction from top to bottom from the mastoid and occipital regions of the brain skull, as well as from the external ear, is located in the subcutaneous tissue and, crossing m. sternocleidomastoideus from the inside outward, approaches the venous jugular angle, angulus venosus juguli, into the anterior surface of which we fall. The cross section of the vessel is subject to significant fluctuations and often reaches the thickness of a pencil. Often in men, this vein is well contoured on the neck, especially in those wearing tight collars.

Rice. 65. Topography of superficial vessels and nerves of the neck.

1-n. auricularis magna; 2-v. jugulans externa; 3-n. cutaneus transversus colli; 4-v. jugulans anterior; 5 – nn. supraclaviculares; 6-n. occipitalis minor.

2. V. jugularis anterior - anterior jugular vein - also a steam room; located on the sides of the median eminences of the neck.

In the lower part of the neck, these veins are located in the suprasternal interaponeurotic space, spatium interaponeuroticum suprasternale, and, therefore, are located here between the proper and middle fascia of the neck, and not in the subcutaneous tissue, which is observed in the upper parts of the neck. In this space, both veins in most cases anastomose with each other with the formation of the jugular venous arch, arcus venosus juguli.

3. V. mediana colli - the median vein of the neck - is located along the white line of the neck in the subcutaneous tissue. Usually there is an inverse relationship in the development of this and the previous veins: in cases where the anterior jugular veins are expressed, the median vein of the neck is absent and vice versa. It must be remembered that there is negative pressure in the veins of the neck (including superficial ones), therefore, even with minor neck injuries, the crossed veins suck in air, which leads to air embolism and often to the death of the patient. For this reason, when treating wounds of the neck, it is necessary first of all to bandage the segments of the crossed veins (Fig. 65.)

SUPERFICIAL NERVE.

All sensitive superficial nerves of the neck come from the cervical plexus, plexus cervicalis (Fig. 66).

For the anterior neck, the cutaneous nerves are the four nerves derived from the four upper cervical nerves. All of them come out, as already mentioned, behind the middle of the rear edge of m. sternocleidomastoideus within trigonum omotrapezoideum.

1. N. cutaneus transversus colli - transverse cutaneous nerve of the neck - innervates the median neck.

2. Nn. supraclaviculares anterior, medius et posterior - anterior, middle and posterior supraclavicular nerves - innervate the lower lateral region of the neck. These nerves, located nearby at first, gradually diverge downwards and spread through the collarbone to the subclavian region. In this case, the anterior supraclavicular nerve bends over the clavicle at its medial end, extremitas sternalis, the middle one approximately through the middle of the clavicle and the posterior one through the outer end of the clavicle, extremitas scapularis.

We have already noted that n. supraclavicularis posterior descends along the outer surface of the shoulder up to the elbow joint, and during conduction anesthesia of the brachial plexus, pain impulses can persist due to this nerve.

3. N. occipitalis minor - small occipital nerve - goes back, describes an arc and ascends to the occipital region; innervates the outer upper region of the posterior neck.

4. N. auricularis magnus - a large ear nerve - the thickest of all the skin branches of the cervical plexus. At the exit from under the rear edge of m. sternocleidomastoideus, it rises and branches within the ear region.

SUPERFICIAL LYMPHATIC SYSTEM.

The superficial lymphatic system of the neck is represented by a network of lymphatic vessels accompanying mainly m. sternocleidomastoideus. On the way, these vessels are interrupted in the superficial cervical lymph nodes, 1-di cervicales superficiales. These nodes in various numbers (most often four or five) lie along the posterior edge, or on the outer surface of the sternocleidomastoid muscle, as well as along v. jugularis externa.

In case of cancerous lesions of the tongue or lip (in advanced cases), the removal of the entire sternocleidomastoid muscle is used along with the entire complex of superficial lymphatic vessels and lymph nodes, as well as the removal of v. jugularis interna together with the system of deep cervical lymph nodes, 1-di cervicales profundi. Excision of the muscle with a block aims at the removal along with the surrounding muscle of the fiber and fascial elements of the entire superficial system of lymphatic vessels and lymph nodes of the neck, which subsequently reduces the percentage of lymphogenous metastases.

Rice. 66. Superficial formations of the neck.

TOPOGRAPHY OF THE NERVOUS VASCULAR BUNCH.

The projection of the main neurovascular bundle of the neck is determined by the line connecting the middle of the fossa retromandibularis with the sternoclavicular joint.

It must be remembered that this projection line is correct only with the head turned to one side.

The composition of the main neurovascular bundle includes the following five formations:

1. A. carotis communis - common carotid artery.

2. V. jugularis interna - internal jugular vein.

3. N. vagus - vagus nerve.

4. Ramus descendens n. hypoglossi - descending branch of the hypoglossal nerve.

5. Truncus lymphathicus jugularis - jugular lymphatic duct.

The syntopy, or relationship, of the elements of the main neurovascular bundle in the neck is as follows.

The most medial is the trunk of the common carotid artery. From the inside, the trachea is adjacent to it and behind the esophagus. Outside of the artery lies the internal jugular vein, which has a much larger cross section. Between these vessels behind in the groove between them (sulcus arteriovenosus posterior) lies the vagus nerve (Fig. 67). The descending branch of the hypoglossal nerve at the top lies on the anterior surface of a. carotis externa and below to the anterior surface of the common carotid artery, along which it descends until it pierces the anterior muscles of the neck, which this branch innervates.

The fifth formation of the neurovascular bundle - the lymphatic jugular duct - is located on the outer or anterior surface of the internal jugular vein in the thickness of the tissue covering it.

All these formations are surrounded by an abundant amount of connective tissue, a sheath covering the entire neurovascular bundle with the formation of a neurovascular container, spatium vasonervorum.

Distinguishing features of the external and internal carotid arteries. When ligating the external carotid artery, which is most often performed as a preliminary stage in operations on the tongue, lip, upper jaw, and m. n. about malignant neoplasms, it is necessary to know the distinguishing features of this artery from a. carotis interna.

These signs are as follows:

1) a. carotis externa - gives off branches on the neck; a. carotis interna does not give branches;

2) a. carotis externa is located medially and anteriorly; a. carotis interna - laterally and backwards.

3) a. carotis externa - at a distance of 1.5–2 cm from the carotid fork, it is crossed by the arch of the hypoglossal nerve, running in the transverse direction and in contact with the external carotid artery (Fig. 68);

4) a sign determined on a living person during the operation is that when a soft clamp is applied to one of the vessels of the carotid fork, the pulsation is checked for a. temporalis superficialis and a. maxillaris externa; if at the same time the pulsation disappears, this vessel is defined as the external carotid artery. It should be emphasized that this sign is subjective and unreliable, since it does not exclude the possibility of error.

Branches of the external carotid artery. Several branches depart from the external carotid artery, supplying blood to various parts of the neck.

Rice. 67. Topography of deep vessels and nerves of the neck.

1-a. carotis communis: 2–n. vagus; 3-r. descendens n. hypoglossi; 4-a. vertebralis; 5 - plexus brachialis; 5-n. accessory.

1. A. thyreoidea superior - the superior thyroid artery - departs from the medial semicircle of the external carotid artery and, giving way to the superior laryngeal artery, a. laryngea superior, enters the upper pole of the lateral lobe of the thyroid gland.

2. A. lingualis - the lingual artery - departs somewhat higher and, having passed through the Pirogovsky triangle, enters the thickness of the tongue.

3. A. maxillaris externa - external maxillary artery - departs from the internal semicircle of the external carotid artery in the submandibular triangle, goes medially from the submandibular gland and bends over the edge of the lower jaw anteriorly from m. masseter. Glandula submaxillaris salivalis at the same time is covered from the outside and from the inside by vessels; outside - v. facialis anterior and inside - a. maxillaris externa.

Rice. 68. Right lateral region of the neck.

1-v. jugularis interna; 2-n. vagus; 3-gl. parotis; 4-a. maxillaris externa; 5-n. hypoglossus; 6-a. lingualis for m. hypoglossus; 7 - os hyoideum; 8-a. thyreoidea superior.

4. A. pharyngea ascendens - ascending pharyngeal artery - departs from the posterior semicircle a. carotis externa and goes to the lateral surface of the pharynx.

5. A. auricularis posterior - posterior auricular artery - departs from the posterior semicircle of the external carotid artery and goes up and back into the mastoid region.

6. A. occipitalis - the occipital artery - is the last vessel of the external carotid artery, leaving the neck; goes under the mastoid process along sulcus a. occipitalis and further into the occipital region, within which it branches.

Terminal branches a. carotis externa are a. temporalis superficialis a. maxillaris interna.

TOPOGRAPHY OF THE CERVICAL PLEXUS

Plexus cervicalis - the cervical plexus - is formed by the anterior branches of the four upper cervical nerves. Upon exiting through the foramina intervertebralia, these nerves lie on the anterior surface of the deep muscles of the neck at the level of the upper four cervical vertebrae behind m. sternocleidomastoideus.

The cervical plexus is formed by sensory, mixed and motor branches. From the first, the cutaneous nerves of the neck described above are formed - n. cutaneus transversus colli, nn. supraclaviculares anterior, medius et posterior, n. auricularis magnus and n. occipitalis minor. A mixed nerve that carries both motor and sensory fibers is n. phrenicus.

Rami musculares plexus cervicis - muscular branches of the cervical plexus - motor branches, innervate the scalene muscles, mm. scaleni anterior, medius et posterior, long muscle of the head and neck, m. longus capitis et colli, rectus capitis, mm. recticapitis.

N. phrenicus - the phrenic nerve - is formed from C 3 and C 4 and lies on the anterior surface of the anterior scalene muscle, m. scalenus anterior, and descends along it into the anterior mediastinum.

In addition to muscle branches to the diaphragm, n. phrenicus gives off numerous sensitive branches to the pleura, pericardium, and peritoneum. Having penetrated with several branches through the foramen quadrilaterum along with v. cava inferior into the abdominal cavity, fibers n. phrenicus are involved in the formation of the diaphragmatic node, ganglion phrenicum. N. phrenicus also gives branches that enter the solar plexus, plexus Solaris, as well as the adrenal plexus, plexus suprarenalis.

It has now been proven that n. phrenicus is involved in the innervation of the stomach; when it is irritated, a reaction occurs from the side of the stomach (the so-called phrenic crisis).

Topography of the brachial plexus.

Plexus brachialis - the brachial plexus - is formed from the anterior branches of the four lower cervical nerves and the first thoracic. These five branches form the three primary bundles (fascicles) of the brachial plexus. Distinguish:

1. Fasciculus primarius superior - the upper primary bundle - is formed by the fusion of the anterior branches of the fifth and sixth cervical nerves.

2. Fasciculus primarius medius - the middle cervical bundle - is a direct continuation of the anterior branch of the seventh cervical nerve.

3. Fasciculus primarius inferior - the lower primary bundle - is formed by the fusion of the anterior branches of the eighth cervical and first thoracic nerves.

Having formed a number of additional anastomoses between these primary bundles, the primary brachial plexus forms three secondary bundles - the medial bundle, fasciculus medialis, the lateral bundle, fasciculus lateralis, and the posterior bundle, fasciculus posterior.

Very often there are various options for the formation of individual bundles and the anastomoses connecting these bundles.

The brachial plexus is divided into two parts: supraclavicular, pars supraclavicularis, and subclavian, pars infraclavicularis.

The supraclavicular part of the brachial plexus at the exit from the interstitial space, spatium interscalenum, is located above a. subclavia.

Above the clavicle, the brachial plexus is crossed transversely by two arteries: a. cervicalis superficialis, below - a. transversa scapulae. Between the trunks of the plexus passes a. transversa colli.

Several branches depart from the pars supraclavicularis plexus brachialis. The most important of them:

1. N. dorsalis scapulae - the dorsal nerve of the scapula - goes down and innervates mm. rhomboidei m. levator scapulae.

2. N. thoracicus longus - the long nerve of the chest - goes down along the linea axillaris anterior and supplies m. serratus anterior.

3. Nn. thoracici anteriores - the anterior nerves of the chest - two of them go down, cover a. subclavia front and back and end in mm. pectorales major et minor.

4. N. suprascapularis - suprascapular nerve - together with the lower abdomen m. omohyoideus goes to the upper scapular notch, incisura scapulae, through which it spreads under the lig. transversum scapulae superior. Innervates m. supraspinatus and m. infraspinatus.

5. Nn. subscapulares - subscapular nerves - two of them go along the anterior surface of the suprascapular muscle and innervate it and m. teres major.

6. N. thoracodorsalis - the dorsal nerve of the chest - goes along the margo axillaris scapulae and innervates m. latissimus dorsi.

TOPOGRAPHY OF THE RETURNING NERVE.

N. recurrens - recurrent nerve - is a branch of the vagus nerve, mainly motor, innervates the muscles of the vocal cords. When it is violated, the phenomena of aphonia are observed - loss of voice due to paralysis of one of the vocal cords. The position of the right and left recurrent nerves is somewhat different.

The left recurrent nerve departs from the vagus nerve at the level of the aortic arch and immediately goes around this arch from front to back, located on its lower, posterior semicircle. Then the nerve rises up and lies in the groove between the trachea and the left edge of the esophagus - sulcus oesophagotrachealis sinister.

In aortic aneurysms, there is compression of the left recurrent nerve by the aneurysmal sac and loss of its conduction.

The right recurrent nerve departs slightly higher than the left one at the level of the right subclavian artery, also flexes it from front to back and, like the left recurrent nerve, is located in the right esophageal-tracheal groove, sulcus oesophagotrachealis dexter.

The recurrent nerve is closely adjacent to the posterior surface of the lateral lobes of the thyroid gland. Therefore, during strumectomy, special care is required when isolating the tumor so as not to damage n. recurrens and do not get disruption of the voice function.

On its way n. recurrens gives branches:

1. Rami cardiacici inferiores - the lower cardiac branches - go down and enter the cardiac plexus.

2. Rami oesophagei - esophageal branches - depart in the region of sulcus oesophagotrachealis and enter the lateral surface of the esophagus.

3. Rami tracheales - tracheal branches - also depart in the region of sulcus oesophagotrachealis and branch out in the wall of the trachea.

4. N. laryngeus inferior - the lower laryngeal nerve - the final branch of the recurrent nerve, lies medially from the lateral lobe of the thyroid gland and is divided into two branches at the level of the cricoid cartilage - anterior and posterior. The anterior innervates m. vocalis. (m. thyreoarytaenoideus interims), m. thyreoarytaenoideus externus, m. cricoarytaenoideus lateralis, etc.

The posterior branch innervates m. cricoarytaenoideus posterior.

TOPOGRAPHY OF THE SUBCLAVIAN ARTERY.

Subclavian artery, a. subclavia, on the right departs from the innominate artery, a. anonyma, and to the left - from the aortic arch, arcus aortae, conditionally it is divided into three segments.

The first segment from the beginning of the artery to the interstitial fissure.

The second segment of the artery within the interstitial fissure.

The third segment - at the exit from the interstitial gap to the outer edge of the 1st rib, where a already begins. axillaris.

The middle segment lies on the 1st rib, on which an imprint remains from the artery - the groove of the subclavian artery, sulcus a. subclaviae.

In general, the artery has the shape of an arc. In the first segment, it goes up, in the second it lies horizontally, and in the third it follows obliquely downwards.

A. subclavia gives off five branches: three in the first segment and one each in the second and third segments.

Branches of the first segment:

1. A. vertebralis - the vertebral artery - departs with a thick trunk from the upper semicircle of the subclavian artery, goes up within the trigonum scalenovertebrale and goes into the foramen transversarium of the VI cervical vertebra.

2. Truncus thyreocervicalis - thyroid trunk - departs from the anterior semicircle a. subclavia is more lateral from the previous one and soon divides into its terminal branches:

a) a. thyreoidea inferior - lower thyroid artery - goes up, crosses m. scalenus anterior and, passing behind the common carotid artery, approaches the posterior surface of the lateral lobe of the thyroid gland, where it enters with its branches, rami glandulares;

b) a. cervicalis ascendens - ascending cervical artery - goes up, located outward from n. phrenicus-and behind v. jugularis interna, and reaches the base of the skull;

c) a. cervicalis superficialis - superficial cervical artery - goes in the transverse direction above the clavicle within the fossa supraclavicularis, lying on the scalene muscles and the brachial plexus;

d) a. transversa scapulae - the transverse artery of the scapula - goes in the transverse direction along the clavicle and, having reached the incisura scapulae, spreads over the lig. transversum scapulae and branches within m. infraspinatus.

3. A. mammaria interna - the internal mammary artery - departs from the lower semicircle of the subclavian artery and goes down behind the subclavian vein to supply the mammary gland.

Branches of the second segment:

4. Truncus costocervicalis - costocervical trunk - departs from the posterior semicircle of the subclavian artery, goes up and soon divides into its final branches:

a) a. cervicalis profunda - deep cervical artery - goes back and penetrates between the 1st rib and the transverse process of the 7th cervical vertebra to the back of the neck, where it branches within the muscles located here;

b) a. intercostalis suprema - the superior intercostal artery - goes around the neck of the first rib and goes to the first intercostal space, which supplies blood. Often gives a branch for the second intercostal space.

Branches of the third segment:

5. A. transversa colli - the transverse artery of the neck - departs from the upper semicircle of the subclavian artery, penetrates between the trunks of the brachial plexus, goes in the transverse direction above the clavicle and at its outer end is divided into its two final branches:

a) ramus ascendens - ascending branch - goes up along the muscle that lifts the scapula, m. levator scapulae;

b) ramus descendens - descending branch - descends along the vertebral edge of the scapula, margo vertebralis scapulae, between the rhomboid and posterior superior dentate muscles and branches both in the rhomboid muscles and in m. supraspinatus. It is important for the development of roundabout blood circulation in the upper limb.

TOPOGRAPHY OF THE BORDER SYMPATIC TRUNK.

The border sympathetic trunk of the neck, truncus sympathicus cervicalis, lies on the sides of the spine in the thickness of the fascia praevertebralis. It is shrouded in connective tissue from all sides, and when it is isolated, it is necessary to cross the fascial layer.

The border sympathetic trunk of the neck is divided into two parts: the upper part, which lies in the upper part of the cervical part of the spinal column, and the lower part, enclosed in the trigonum scalenovertebrale.

Sympathetic ganglia are located along the sympathetic trunk, the number of which varies from two to six (IA Ageenko, 1949).

The superior cervical ganglion, ganglion cervicale superius, is constantly observed at the level of the II–III cervical vertebra. The trigonum scalenovertebrale contains the middle cervical ganglion, ganglion cervicale medium, which is not always found. Almost next to it at the level of the VI cervical vertebra (in about 70% of cases - below) is the intermediate cervical ganglion - ganglion cervicale intermedium - which is also not always found. From the middle cervical ganglion, the loop of the subclavian artery, ansa subclavia (Vieussenii), extends upward in a loop-like manner covering the subclavian artery.

The lower cervical ganglion, ganglion cervicale inferius, is always found; it is located at the level of the transverse process of the VII cervical vertebra behind the subclavian artery. Most often, this ganglion is attached to or grows together with the first thoracic ganglion and in these cases is called the stellate ganglion, ganglion stellatum. This last ganglion is located on the border between the neck and chest.

From the upper, middle, intermediate and lower ganglia depart cardiac nerves, nn. cardiacici superior, medius, intermedius et inferior, which carry accelerating impulses to the heart (through rami accelerantes). The inferior nerve is called Pavlov's nerve.

The cardiac nerves vary in origin, number, course, and persistence. The entire cervical border trunk takes part in the innervation of the heart. The branches of the middle part of the trunk - from the middle and intermediate ganglia in their development prevail over the rest. The thickest are, as a rule, the middle cardiac nerves.

It should be remembered that the stellate ganglion, with its numerous branches, is closely connected with the thoracic duct, braiding it, and during cervical sympathectomy, the latter can be damaged. There are frequent cases when the thoracic duct opens into the venous system with several mouths (two, three, four, and even five), and any of the lymphatic ducts can loop around the interganglionic branches of the sympathetic trunk. In these cases, during the operation of sympathectomy of the cervical part, one of the lymphatic ducts can be torn at the time of removal of the sympathetic trunk and a significant lymphorrhea can be obtained.

We have already emphasized that the sympathetic border trunk of the neck is a very important part of the autonomic nervous system, which is often blocked during many surgical interventions on the chest and abdominal cavity (the so-called vagosympathetic blockade according to A. V. Vishnevsky).

The border trunk in 75% of cases passes to the left in front of the inferior thyroid artery; in other cases - behind her. On the right, the border trunk crosses the inferior thyroid artery in front in 64%, in other cases - behind (I. A. Ageenko, 1949).

The sympathetic border trunk in all cases is connected by anastomoses with the vagus nerve. Its anastomoses are very often observed with the glossopharyngeal nerve and in rare cases with the hypoglossal nerve (IA Ageenko, 1949).

Surgical access to the cervical part of the border sympathetic trunk is carried out along the anterior and posterior edges of the sternocleidomastoid muscle. An incision along the anterior edge of this muscle is less traumatic and through it it is easier to understand the surrounding anatomical formations.

DEEP LYMPHATIC SYSTEM OF THE NECK.

Deep cervical lymphatic vessels, vasa lymphatica cervicalia profunda and accompanying deep cervical lymph nodes, 1-di cervicales profundi, are located mainly along the main neurovascular bundle of the neck.

Lymphatic vessels form a common trunk - truncus lymphaticus jugularis, adjacent to v. jugularis interna front and outside.

Deep cervical lymph nodes, located in the form of a chain along the jugular vein, are divided into two groups: the upper deep cervical lymph nodes, 1-di cervicales profundi superiores, and the lower deep cervical lymph nodes, 1-di cervicales profundi inferiores, otherwise called supraclavicular, 1-di supraclaviculares. The upper lymph nodes lie in number 10-16 within the trigonum caroticum; the lower ones, 10–15 in number, are located in the fossa supraclavicularis.

Most of the head lymph passes through the upper cervical and supraclavicular lymph nodes. The vasa efferentia of these nodes merge into the truncus lymphaticus jugularis on both sides.

In this case, the right jugular lymphatic duct flows into the right lymphatic duct, ductus lymphaticus dexter, and the left one directly into the ductus thoracicus.

Damage to the thoracic duct in the neck in the region of the left supraclavicular fossa usually causes the outflow of a large amount of lymph (lymphorrhea), exhaustion and death of the patient, if timely surgical intervention is not performed. The amount of lymph released after injury to the duct reaches several liters per day (up to 13).

In addition to the upper deep cervical and supraclavicular lymph nodes, there are several smaller lymph nodes in the neck area in the larynx, trachea and behind the pharynx. L-di retropharyngeae - retropharyngeal lymph nodes, including 3-5 small nodules, are located on the back wall of the pharynx; receive lymph from the middle ear, from the nasopharynx and soft tissues surrounding the pharynx. L-di praelaryngeales - 1-2 preglottic lymph nodes are located on the lateral surface of the upper part of the larynx. L-di praetracheales - pretracheal lymph nodes lie on the lateral surface of the upper tracheal rings; receive lymph from the initial part of the trachea and from the thyroid gland.

With advanced cancer of the tongue or lip, a radical operation is used to remove the lymphatic apparatus of the neck, while the internal jugular vein is excised along with the network of lymphatic vessels enveloping it and adjacent lymph nodes, and the sternocleidomastoid muscle is also excised on the affected side along with the superficial lymphatic system neck (Crail operation).

ELEVATIONS IN THE MIDDLE LINE OF THE NECK.

Four elevations are observed along the midline of the neck, partly noticeable on examination, partly well palpable when running a finger along the midline of the neck. If palpated from top to bottom, these elevations are as follows (Fig. 69):

1. Eminentia ossis hyoidei - the elevation of the hyoid bone - due to its body. On examination, it is not determined, it is palpated well.

2. Eminentia cartilaginis thyreoidei s. pomum Adami - the elevation of the thyroid cartilage or "Adam's apple" - in men it is clearly expressed, clearly visible and protrudes significantly anteriorly; in women, this elevation is not contoured due to the uniform deposition of subcutaneous fat. Feels quite distinct.

A dense fibrous plate, membrana thyreohyoidea, is stretched between the hyoid bone and the thyroid cartilage.

In the upper part of the thyroid cartilage, incisura thyreoidea is clearly palpable between the lateral plates of the thyroid cartilage.

3. Eminentia cartilaginis cricoidea - the elevation of the cricoid cartilage - is located under the thyroid cartilage. When probing between the lower edge of the thyroid cartilage and the cricoid cartilage, a regular oval-shaped fossa is noticeable. It is closed by the cricoid-thyroid or conical ligament, lig. cricothyreoideum s. lig. conicum.

4. Eminentia isthmi glandulae thyreoideae - the elevation of the isthmus of the thyroid gland - is not detected during examination, a soft consistency formation is noted by palpation, which lies directly under the cricoid cartilage.

Rice. 69. Projection of the organs of the neck.

1 - os hyoideum, 2 - cartilage thyreoidea; 3 - cartilage cricoidea.

LAYERED TOPOGRAPHY OF THE SUPRAHYLINGUAL AREA

In the suprahyoid region there are the following layers:

1. Derma - skin - does not present features.

2. Panniculus adiposus - subcutaneous fatty tissue - expressed to varying degrees.

3. Lamina externa fasciae superficialis - the outer plate of the superficial fascia - in the form of a thin, muslin-like plate covers the subcutaneous muscle of the neck from the outside.

4. Platysma myoides s. m. subcutaneus colli - subcutaneous muscle of the neck.

5. Lamina interna fasciae superficialis - the inner plate of the superficial fascia - covers the subcutaneous muscle of the neck from the inside.

6. Fascia colli propria - own fascia of the neck - fuses with the previous fascia and loosely lines the entire suprahyoid region.

7. Fascia colli media - the middle fascia of the neck - lines the bottom of the diaphragm of the oral cavity and the anterior bellies of the digastric muscles.

8. Venter anterior m. digastrici - the anterior belly of the digastric muscle - is located on both sides. sides of the midline and wrapped in the middle fascia of the neck.

9. M. mylohyoideus - maxillofacial, muscle - forms the diaphragm of the mouth; the muscle begins along the linea mylohyoidea, goes to the median line, and here fuses with the same muscle of the opposite side to form a longitudinally running suture, raphe.

10. M. geniohyoideus - the geniohyoid muscle - lies above the previous muscle on the sides of the midline and also in the sagittal direction.

Rice. 70. Cross section of the neck (semi-schematically).

1 - platysma myoides; 2 - m. sternocleidomastoideus; 3 - fascia colli propria; 4 - m. omohyoideus; 5 - m. sternohyoideus; 6 - m. sternothyreoidus; 7 - thyroid gland; 8 - capsule of the thyroid gland; 9 - sheath of the neurovascular bundle; 10-v. jugularis interna; 11 - n. vagus; 12 - a. carotis communis; 13 - n. recurrences; 14 - esophagus; 15 - m. longus colli; 16 - fascia praevertebralis; 17 - truncus sympathicus.

11. Glossus s. lingua - language - more precisely, its lingual-hyoid muscle, m. hyoglossus, and above - the rest of the muscles of the tongue.

12. Cavum oris proprium - the actual oral cavity, lined with mucous membranes.

Layers of the sublingual region.

In the sublingual region, surgical interventions are most often used, since most of the most important organs of the neck lie here (Fig. 70).

1. Derma - skin - thin, elastic, easily displaced. Langer's lines of skin tension are located in the transverse direction, as a result of which horizontal incisions on the neck less often give the formation of hypertrophic keloid scars.

2. Panniculus adiposus - subcutaneous fatty tissue - varies greatly in its development depending on the degree of fatness. In women, as usual, it is more developed and lines the deeper layers more evenly.

3. Lamina externa fasciae superficialis - the outer plate of the superficial fascia - is a continuation of the superficial fascia of the face, goes down, covering the subcutaneous muscle of the neck, m. subcutaneus colli, and passes to the anterior chest wall.

4. M. subcutaneus collis. platysma myoides - the subcutaneous muscle of the neck - begins on the lower third of the face and goes down in the form of a thin muscular plate, spreading over the collarbone and ending on the chest wall. In the midline of the neck, this muscle is not represented and is replaced by connective tissue fascia.

Due to the fact that there are no neck muscles along the midline, and there is only a junction line of the fascia of the right and left half of the neck, a white neck line, linea alba colli, is formed here, located strictly in the middle of the anterior neck in a vertical direction.

5. Lamina interna fasciae superficialis - the inner plate of the superficial fascia - is quite similar to the outer plate, but behind the subcutaneous muscle of the neck. Thus, platysma myoides is located in the sheath of the superficial fascia of the neck.

6. Fascia colli propria - own fascia of the neck - is a rather dense connective tissue plate. On the sides of the midline, this fascia splits and forms a sheath for the sternocleidomastoid muscle, and in the back of the neck, a sheath for the trapezius muscle. Therefore, medial m. sternocleidomastoideus, this fascia is represented by one plate, at the level of the muscle it consists of two sheets and lateral to the muscle - again from one fascial plate.

7. Spatium interaponeuroticum suprasternale et supraclaviculare - supraclavicular and supraclavicular interaponeurotic space - located only in the lower part of the subhyoid region. It is formed due to the attachment of fascia colli propria to the anterior edge of the sternum and clavicle, and fascia colli media to the posterior edge. As already mentioned, this space is filled with adipose tissue.

8. Lamina anterior fasciae colli mediae - the anterior plate of the middle fascia of the neck - covers the anterior muscles of the neck. Fascia forms sheaths for the anterior neck muscles. Therefore, going from the midline, the single plate of this fascia first meets, then, splitting, it covers the anterior muscles of the neck and laterally again turns into a single plate.

9. Stratum musculare superficial - the superficial muscle layer - is represented by the following muscles:

1) M. sternohyoideus - the sternum o-hyoid muscle - starts from the manubrium sterni and is attached to the body of the hyoid bone.

2) M. sternothyreoideus - sternum o-thyroid muscle - also starts from the handle of the sternum and is attached to the lateral plate of the thyroid cartilage in the linea obliqua region.

3) M. thyreohyoideus - the thyroid-hyoid muscle - begins at the place of attachment of the previous muscle on the thyroid cartilage from the oblique line, linea obliqua, and is attached to the large horns of the hyoid bone.

4) M. omohyoideus - scapular-hyoid muscle - consists of the upper abdomen, venter superior and lower abdomen, venter inferior; stretches in an oblique direction from the scapular notch, incisura scapulae, to the body of the hyoid bone. The middle, in the form of a bridge, tendon part of the muscle is connected with the sheath of large vessels.

The muscle is of great importance in the formation of neck triangles.

mm. sternohyoideus, sternothyreoideus m. omohyoideus are innervated by ramus descendens n. hypoglossy, m. thyreohyoideus receives a separate branch directly from the arch of the hypoglossal nerve, arcus n. hypoglossi, called ramus thyreohyoideus.

10. Lamina interim fasciae colli media - the inner plate of the middle fascia of the neck - covers the front muscles of the neck from behind.

Thus, the middle fascia of the neck below the hyoid bone is a receptacle for four muscles - m. sternohyoideus, m. sternothyreoidus, m. omohyoideus, m. thyreohyoideus.

11. Spatium praeviscerale - previsceral space - is located in the form of a narrow frontal gap between the middle fascia of the neck and the deeper pretracheal fascia lining the trachea in front.

12. Fascia praetrachealis - pretracheal fascia - covers the trachea in front and, diverging to the sides, gradually becomes thinner and disappears.

13. Cavum colli - the cavity of the neck - is a space lined with fascia endocervicalis, which contains the main organs of the neck: trachea, esophagus, main neurovascular bundle, etc. This cavity has the shape of a semi-cylinder, the convex side is directed anteriorly and truncated - posteriorly.

14. Spatium retroviscerale - retrovisceral space - is enclosed in the form of a frontal gap between the posterior surface of the esophagus and the prevertebral fascia.

15. Fascia praevertebralis - prevertebral fascia - massive, thick, but loose and easily stretchable connective tissue lining the spine and covering the deep muscles of the anterior neck - m. longus capitis and m. longus colli. Diverging to the sides, this fascia forms fascial sheaths for the scalene muscles.

16. Stratum musculare profundum - deep muscle layer - consists of the following five muscles:

M. longus colli - the long muscle of the neck - lies most medially on the lateral spine, leaving the middle spine uncovered by muscles. It stretches from the atlas to the third thoracic vertebra.

M. longus capitis - the long muscle of the head - lies outward from the previous one and starts from the transverse processes of the III-IV cervical vertebrae and is attached to the body of the occipital bone.

M. scalenus anterior - scalenus anterior - lies even more outward than the previous one. It starts with separate teeth from the anterior tubercles of the transverse processes of the III-IV cervical vertebrae and is attached to the tuberculum scaleni (s. Lisfranci)

M. scalenus medius - the middle scalene muscle - lies lateral to the anterior scalene muscle. It starts with teeth from the anterior tubercles of all seven or six transverse processes of the cervical vertebrae and is attached to the upper surface of the 1st rib. A triangular gap is formed between the last muscles - the interstitial space, spatium interscalenum, through which a. subclavia and plexus brachialis.

M. scalenus posterior - posterior scalene muscle - starts from the anterior tubercles of the transverse processes, but only the V and VI cervical vertebrae, and is attached to the outer surface of the II rib. This muscle occupies the outermost position in relation to the previous muscles.

All these five muscles are innervated by the anterior branches of the cervical plexus, segmentally entering the lateral surface of these muscles. M. longus colli is innervated from C 2 -C 6, m. longus capitis - from C 1 -C 5, m. scalenus anterior from C 5 -C 7, m. scalenus medius - from C 5 -C 8, m. scalenus posterior - from C 7 -C 8.

17. Pars cervicalis columnae vertebralis - the cervical part of the spinal column.

The pre- and post-visceral spaces of the neck are of great clinical importance, since deep phlegmons of the neck descend along them with injuries of the trachea and esophagus, spreading down into the anterior or posterior mediastinum with the development of mediastinitis.

Along the midline of the neck, at the junction of the fascia of either side, there is a white line of the neck, linea alba colli, along which median longitudinal incisions are made to access the larynx, trachea, and thyroid gland.

It should be remembered that there are no muscles along the midline, and the fascia merge into a single loose plate.

PHARYNX.

Pharynx - pharynx - is a cone-shaped or funnel-shaped muscular tube directed downward by its narrowed section. At the top, it is attached to the base of the skull, at the bottom, at the level of the VI cervical vertebra, it passes into the esophagus.

The boundaries of fixation of the pharynx to the base of the skull are as follows: from tuberculum pharyngeum, the line of attachment of the pharynx goes in both directions, crossing the pars basilaris ossis occipitalis in the transverse direction, then outwardly the pharynx is attached to the spina angularis of the main bone and ends on the lamina medians processus pterygoideus.

The pharyngeal cavity, cavum pharyngis, is divided into three floors or parts.

1. Pars nasalis pharyngis s. epipharynx, s. nasopharynx - the nasal part or nasopharynx - extends from the arch of the pharynx, fornix pharyngis, to the palatum molle. This part of the pharynx has only the back and side walls; the anterior wall is represented by openings - choanami, choanae, which communicate the pharyngeal cavity with the nasal cavity. On the side wall of the nasopharynx lies the pharyngeal opening of the auditory (Eustachian) tube, ostium pharyngeum tubae auditivae (Eustachii).

2. Pars oralis pharyngis s. mesopharynx s. oropharynx - the oral part of the pharynx, otherwise the oropharynx - extends from the level of the soft palate to the entrance of the larynx, aditus laryngis.

The anterior wall of the oropharynx communicates with the oral cavity by the mouth of the pharynx, isthmus faucium.

3. Pars laryngea pharyngis, s. hypopharynx, s. laryngopharynx - the laryngeal part of the pharynx or laryngopharynx - extends from aditus laryngis to the lower edge of the cricoid cartilage at the level of the VI cervical vertebra, where the pharynx passes into the esophagus (Fig. 71).

The walls of the pharynx are formed by the main three layers: the outer connective tissue membrane, tunica adventitia, the middle - muscular membrane, tunica muscularis, and the internal mucous membrane, tunica mucosa.

The muscular apparatus of the pharynx is represented by muscles that lift and expand the pharynx, m. stylopharyngeus et m. palatopharyngeus, and muscles that compress the pharynx, mm. constrictores pharyngis.

Rice. 71. floorspharynx.

I, pars nasalis pharyngis; II - pars oralis pharyngis; III - pars laryngea pharyngis. 1 - fornix pharyngis; 2 - ostium pharyngeum tubae; 3 - uvula; 4 - aditus laryngis; 5 - conche.

1. M. stylopharyngeus - the stylopharyngeal muscle - starts from the processus styloideus and is woven into the lateral surface of the pharynx.

2. M. palatopharyngeus - palatopharyngeal muscle - is enclosed in the posterior palatine arch, arcus palatopharyngeus.

3. M. constrictor pharyngis superior - the upper constrictor of the pharynx - starts from the base of the skull and, having formed the side walls of the pharynx, converges behind with the formation of the pharyngeal suture, raphe pharyngis.

4. M. constrictor pharyngis medius - the middle constrictor of the pharynx - starts from the large and small horns of the hyoid bone, cornua majora et minora ossis hyoidei, fan-shaped to the sides and also ends behind with the formation of raphe pharyngis.

5. M. constrictor pharyngis inferior - lower pharyngeal constrictor - starts from the thyroid and partially cricoid cartilages, muscle fibers are also intertwined behind to form raphe pharyngis.

On the mucous membrane of the lower part of the pharynx, on the sides of aditus laryngis, there is a recess - a pear-shaped pocket, recessus piriformis. Foreign bodies linger in this recess. On the mucous membrane lining this recess there is an oblique fold, plica n. laryngei, which contains the superior laryngeal nerve, n. laryngeus superior.

Syntopy of the pharynx: behind is the pharyngeal space, spatium retropharyngeum; it is enclosed between the posterior surface of the pharynx and the fascia praevertebralis.

On the sides of the pharynx is the right and left peripharyngeal spaces, spatii parapharyngei, dextrum et sinistrum. Here lie the carotid vessels and internal jugular veins, as well as muscles - m. styloglossus, m. stylopharyngeus, m. stylohyoideus - the so-called anatomical bouquet, starting from the processus styloideus.

The muscular skeleton of the pharynx is covered with pharyngeal fascia, fascia pharyngea.

The blood supply of the pharynx is carried out by the ascending pharyngeal artery, a. pharyngea ascendens, which is a branch of a.carotis externa. It ascends along the lateral surface of the pharynx, giving branches to its walls.

The region of the pharyngeal tonsil, tonsilla pharyngea, and the circumference of the ostium pharyngeum tubae auditivae are supplied with blood by a. palatina ascendens.

Innervation of the pharynx is carried out from the pharyngeal plexus, plexus pharyngeus, formed by sensory and motor branches v. vagus and n. glossopharyngeus.

The pharyngeal constrictor is innervated by rami pharyngei n. vagi.

Lymph outflow from the walls of the pharynx is directed in the upper part of the pharynx to the retropharyngeal lymph nodes l-di retropharyngeae, and then to the deep upper cervical lymph nodes, l-di cervicales profundi superiores. From the lower pharynx - directly into the deep cervical lymph nodes, bypassing the pharynx.

LARYNX.

The larynx, larynx, is located between the upper edge of the V to the lower edge of the VI cervical vertebrae, m. e. lies within two cervical vertebrae. It consists of an unpaired thyroid cartilage, cartilage thyreoidea, an unpaired cricoid cartilage, cartilage cricoidea, two arytenoid cartilages, cartilagines arytaenoideae, and an epiglottis, epiglottis.

The thyroid cartilage consists of two plates, lamina thyreoidea, which fuse in front to form the thyroid notch, incisura thyreoidea. In the posterior upper section, the upper horns, cornua superiora, depart from the thyroid cartilage, in the posterior lower section, the lower horns, cornua inferiora.

The cricoid cartilage lies below the thyroid. With a wide part, it is directed back, and with a narrow half-ring - anteriorly. A ligament is stretched between these cartilages - lig. cricothyreoideum s. conicum - cricoid-thyroid or conical ligament.

The arytenoid cartilages are adjacent to the thyroid cartilage at the back. Each of them can be compared to an irregular three-sided pyramid. In the arytenoid cartilage, there are: the base, basis, and the apex, apex. The base has a muscular process, processus muscularis, and a vocal process, processus vocalis. Two muscles are attached to the muscle process - mm. cricoarytaenoidei posterior et lateralis; the true vocal cord is attached to the vocal process.

From above, the entrance to the larynx, aditus laryngis, is covered when swallowing with the epiglottis.

Between the thyroid cartilage and the hyoid bone is a fibrous plate - membrana thyreohyoidea.

The muscles of the larynx are divided into external and internal groups. The first includes only one muscle - m. cricothyreoideus - cricothyroid muscle - the strongest muscle of the larynx. It is stretched between the arch of the cricoid cartilage and the thyroid cartilage; during contraction, it brings both of these cartilages together and strains the vocal cords.

The internal muscles of the larynx include a number of muscles, of which we will indicate the most important.

1. M. cricoarytaenoideus posterior - posterior cricoid-arytenoid muscle - stretches from the cricoid cartilage to the muscular process of the arytenoid, pulls the muscular process back and expands the glottis.

2. M. cricoarytaenoideus lateralis - the lateral cricoarytenoid muscle - is also stretched between the cricoid cartilage and the muscular process of the arytenoid, pulls the muscular process forward and narrows the glottis.

3. M. thyreoarytaenoideus interims s. m. vocalis - internal thyroid-arytenoid or vocal muscle - is enclosed in the thickness of the true vocal cord. It is directly adjacent from the inside to the external thyroid-arytenoid muscle. The muscle bundles run in the sagittal direction and are stretched between the thyroid cartilage and the vocal process of the arytenoid. With the contraction of this muscle, the vocal cords become shorter and thicker, the true vocal folds approach each other, and the glottis narrows.

4. M. thyreoarytaenoideus externus - external thyroid-arytenoid muscle - adjoins the previous muscle from the outside; narrows the glottis.

The cavity of the larynx, cavum laryngis, is divided into three floors: the upper one is the vestibule of the larynx, vestibulum laryngis, the space from the entrance to the larynx to the upper so-called false vocal cords, ligamenta vocalia spuria; on the sides of the vestibule of the larynx are symmetrically two recesses, called pear-shaped pockets, recessus piriformes. These pockets are of great clinical importance, since foreign bodies get into them, from where they have to be removed; the middle floor, mesolarynx, is enclosed between the overlying false and underlying true vocal cords, ligamenta vocalia vera. Here, depressions are observed on the sides, called laryngeal or morganian ventricles, ventriculi laryngis.

The lower floor of the larynx cavity - hypolarynx - the space located below the true vocal cords.

Blood supply to the larynx is carried out by the upper and lower laryngeal arteries a. laryngea superior and a. laryngea inferior. The first is a branch a. thyreoidea superior, the second - and thyreoidea inferior.

The larynx is innervated by sensory and motor branches of the sympathetic and vagus nerves.

1. N. laryngeus superior - the superior laryngeal nerve - departs from the vagus nerve in the region of the lower ganglion nodosum and is divided into two branches behind the large horn of the hyoid bone:

1) Ramus externus - the outer branch - of a mixed nature, innervates m. cricothyreoideus and the mucous membrane of the larynx.

2) Ramus internus - the inner branch - perforates the membrana hyothyreoidea and sends sensitive branches to the mucous membrane of the larynx.

2. N. laryngeus inferior - the lower laryngeal nerve - is a branch of the recurrent nerve. Innervates the internal muscles of the larynx listed above. If it is damaged, non-closure of the vocal cords and the phenomenon of aphonia are observed.

Lymph outflows from the larynx are carried out to the upper deep cervical lymph nodes - 1-di cervicales profundi superiores, to the lower deep cervical lymph nodes, 1-di cervicales profundi inferiores, and also to the pre-laryngeal lymph node 1-dus praelaryngeus, lying on the lig. conicum.

THYROID TOPOGRAPHY

Thyroid gland, glandula thyreoidea. consists of the right and left lobes, lobus dexter et lobus sinister, and isthmus glandulae thyreoideae. In addition, in * / s cases there is a pyramidal lobule, lobus pyramidalis, which in the form of a cone-shaped process rises to the lateral plate of the thyroid cartilage.

The isthmus of the thyroid gland is located at the level of the two upper tracheal cartilages; both lobes are directed backward and cover the trachea from the sides in a horseshoe shape. With the help of rather dense connective tissue, the isthmus of the thyroid gland is fixed to the tracheal rings.

It must be remembered that due to such an intimate fit of the isthmus to the trachea, there is a single system of blood supply to the isthmus and cartilage of the trachea. During the operation of the upper tracheotomy, the child has a risk of impaired blood supply to the upper tracheal rings when the isthmus is pulled down due to damage to the vessels connecting these organs. For this reason, in children, it is preferable to do an inferior tracheotomy, leaving the isthmus intact.

The thyroid gland is covered with two capsules: an outer capsule, capsula externa, made of dense connective tissue and an internal fibrous own capsule, capsula interna. The latter sends dense partitions inside the gland and for this reason cannot be removed from the gland. Both capsules are very loosely interconnected. In the slit-like space between them lie the vessels and nerves leading to the gland, as well as the parathyroid glands.

Due to the loose connection of the two capsules, exfoliation of the gland during surgery is not difficult.

The lateral lobes of the thyroid gland are adjacent on both sides to the esophageal-tracheal grooves, sulci oesophagotracheales dexter et sinister, in which the recurrent nerves are located. Here, the excision of a thyroid tumor requires special care, since a frequent severe complication during surgery is damage to the recurrent nerves with the development of aphonia in the patient.

Rice. 72. Thyroid syntopyglands.

1 - thyroid gland; 2 - platysma myoides; 3 - m. sternocleidomastoideus; 4-a. carotis communis; 5 - spine; 6-v. jugularis interna; 7 - m. omohyoideus; 8 - esophagus; 9-n. recurrences.

In the outer sections, the lateral lobes of the thyroid gland are adjacent to the main neurovascular bundle of both sides (Fig. 72).

The lower ends of the lateral lobes extend down to the level of the 5th–6th tracheal rings; the upper ones reach the middle of the cartilage thyreoidea.

Directly on the gland is m. sternothyreoideus, and this muscle is covered by two more: m. sternohyoideus m. omohyoideus. Only along the midline is the isthmus not closed by muscles. Behind the lateral lobes, as said, the neurovascular bundles are adjacent. At the same time a. carotis communis directly touches the gland, leaving a corresponding imprint on it - a longitudinal groove. Even more medially, the lateral lobes touch in the upper part of the pharynx, and below - the side wall of the esophagus.

The outer capsule of the thyroid gland is fused with adjacent parts of the middle fascia of the neck and with the sheath of the neurovascular bundle.

Being fixed by the isthmus to the trachea, the gland follows all its movements in the process of breathing.

Variations in the development of the thyroid gland are often manifested in the absence of an isthmus. In these cases, the organ is paired. Sometimes there are additional thyroid glands glandulae thyreoidea accessoriae.

The blood supply of the gland comes from: 1. A. thyreoidea -superior - the superior thyroid artery - a steam room, departs from the external carotid artery and enters the posterior section of the upper pole of the lateral lobe of the gland; supplies blood mainly to the anterior part of the organ.

Rice. 73. blood supplythyroidglands.

1-a. thyreoidea inferior; 2-n. recurrences; 3-a. thyreoidea superior; 4-n. phrenicus; 5 - plexus brachialis.

2. A. thyreoidea inferior - the lower thyroid artery - departs from the truncus thyreocervicalis and enters the posterior surface of the lower pole of the gland; supplies blood mainly to the posterior part of the organ (Fig. 73).

3. A. thyreoidea ima - unpaired thyroid artery - is a branch of the aortic arch directly, occurs in 10% of cases, rises upward and protrudes into the lower edge of the isthmus of the thyroid gland

Venous outflow is carried out along the veins of the same name, w. thyreoideae superiores et inferiores, into the jugular vein system. From the isthmus, blood is directed down the v. thyreoidea ima - an unpaired vein of the thyroid gland, which below within the spatium interaponeuroticum suprasternale et supraclaviculare forms a venous unpaired plexus, plexus venosus impar.

Roundabout circulation of the thyroid gland. There are five major arteries that feed the thyroid gland. Four of them approach the lobes of the thyroid gland, and one in the midline to the isthmus; it also nourishes the lobus pyramidalis in cases where this share is expressed. The lateral lobes of the thyroid gland are approached from the side of the upper pole a. thyreoidea superior (branch a. carptis externa), and from the side of the inner-posterior surface of the lobes a. thyreoidea inferior (branch of truncus thyreocevicalis).

A thyreoidea ima (departing from a. anonyma or arcus aortae) approaches the isthmus or pyramidal lobe of the thyroid gland. Thus, both on the surface and in the thickness of the thyroid gland, abundant anastomoses of several orders are formed between these arteries; when one, two or more arteries supplying the thyroid gland from various sources are turned off, roundabout blood circulation is restored due to the remaining arteries. The same thing happens when ligating the main venous trunks of the thyroid gland that accompany the corresponding arteries. The bed of veins significantly exceeds the corresponding arteries in diameter; due to branches v. thyreoidea ima is formed by plexus venosus thyreoideus impar. When studying the entire vascular system of the thyroid gland as a whole, our attention should be directed to the main sources from which the vessels that feed it emerge. These sources are: aa. carotides externae, aa. subclaviae et a. anonyma or aortic arch.

Rice. 74. Roundabout after ligation of the common carotid artery.

1-a. thyreoidea .superior (dextra et sinistra); 2-a. thyreoidea inferior (dextra et sinistra); 3-a. thyreoidea ima.

Having studied all sources of blood supply gl. thyreoidea, it is easy to imagine the ways of restoring the roundabout arterial circulation as in gl. thyreoidea when one or more thyroid arteries are switched off, and when a. subclavia before the truncus thyreocervicalis leaves and at any level a. carotis communis or a. carotis externa (Fig. 74). The specified circle of roundabout blood circulation of the thyroid gland is of great importance in the restoration of cerebral circulation in the case of ligation of a. carotis communis at any of its levels, since the blood through the circuitous circulation of the thyroid gland through the a. carotis externa and sinus caroticus can enter the system a. carotis interna to the brain, with blocked a. carotis communis of the respective party.

In addition, a. transversa scapulae, departing along with a. thyreoidea inferior from truncus thyreocervicalis. When dressing a. subclavia in the proximal section along a. transversa scapulae blood enters the vessels of the shoulder girdle, the distal third of a. subclavia and a. axillaris.

Lymph outflow from the gland is partly directed along the system of superficial lymphatic vessels, vasa lymphatica superficialia to the superficial cervical lymph nodes, 1-di cervicales superficiales along the sternocleidomastoid muscle, and mainly to the system of supraclavicular lymph nodes 1-di supraclaviculares and pretracheal lymph nodes. nodes 1-di praetracheales. From here, the lymph goes to the next barrier - the deep lower cervical lymph nodes, 1-di cervicales profundi inferiores.

The nerves of the gland come from the sympathetic and vagus nerves. They reach the gland as part of the plexuses accompanying the superior and inferior thyroid arteries.

TOPOGRAPHY OF PARATHYROID GLANDS.

The number of parathyroid or epithelial glands, glandula parathyreoidea, varies from 1 to 8. Most often there are two pairs. The upper pair lies between the outer and inner capsules of the thyroid gland at the level of the cricoid cartilage in the middle of the distance between its upper pole and the isthmus of the gland. In this case, the parathyroid glands are adjacent to the lateral lobes of the thyroid gland behind.

The lower pair of glands is located at the lower poles of the lateral lobes of the thyroid gland in the area where the inferior thyroid artery enters. Each gland is an elongated or rounded formation 4–8 mm in length, 3–4 mm in width, m. e. the size of a small pea. In order to preserve these glands during removal of the thyroid gland, a part of the thyroid gland should be cut off and all branches into which a. thyreoidea inferior, forming, as it were, a “panicle” of vessels. Preservation of at least one piece of iron is necessary, since otherwise it will lead to the development of parathyroid therapy in the patient. In case of a malignant tumor of the gland (struma maligna), it is necessary to remove the organ within healthy tissues; therefore , the parathyroid glands are removed, but the patient is subsequently administered endocrine preparations.

TOPOGRAPHY OF THE VENOUS JUGULAR ANGLE.

Angulus venosus juguli - jugular venous angle - formed by the connection of the internal jugular vein, v. jugularis interna, with subclavian vein, v. subclavia, which merge to form the innominate vein, v. anonymous. It is located within the trigonum omoclaviculare and corresponds to the triangle that lies deeper here - trigonum scalenovertebrale.

The thoracic duct, ductus thoracicus, flows into the left jugular venous angle.

The right lymphatic duct, ductus lymphaticus dexter, flows into the right venous angle.

Ductus thoracicus, before its confluence, forms a lymphatic arch, arcus lymphaticus, with a bulge directed upwards. Penetrating into the gap between the common carotid and subclavian arteries,

the thoracic duct goes to the lateral side in the slit-like gap between the vertebral artery and the internal jugular vein and, having formed an extension - the lymphatic sinus, sinus lymphaticus, flows into the left venous jugular angle.

Often the thoracic duct flows into the subclavian vein or into the jugular vein (Fig. 75).

In the presence of multiple ducts, the latter open into different veins - the internal jugular, into the venous angle, into the subclavian vein. This is essential in case of damage to the thoracic duct in the neck and, if necessary, to ligate it for lymphorrhea. In this case, it is necessary to block all its ducts, since otherwise the outflow of lymph will continue.

Rice. 75. Variations of the confluence of the thoracic duct (according to V.X. Frauci).

It should be borne in mind that the lymphatic arch can "be located at the level of the V cervical vertebra, at the level of the VII cervical vertebra, and most often at the level of the VI cervical vertebra (M. S. Lisitsyn V. X. Frauchi). In more rare cases, it is known the confluence of the thoracic duct into other veins.Thus, its confluence into the right venous angle, into the vertebral and other veins is described (S. Minkin, 1925; G. M. Iosifov 1914).

The lymphatic cervical arch in relation to the stellate ganglion can be located differently. It may lie above it, below or lateral to this sympathetic node. There are cases when the branches of the sympathetic trunk loop around the lymphatic arch, which is of great importance when performing cervical sympathectomy. In this case, the said loop can rupture the thoracic duct and cause significant lymphorrhea.

Within the trigonum omoclaviculare, the following enter the thoracic duct:

1. Truncus lymphaticus jugularis sinister - the left jugular lymphatic trunk - collects lymph from the left half of the head and accompanies the left internal jugular vein on the neck.

2. Truncus lymphaticus subclavius ​​sinister - the left lymphatic subclavian trunk - collects lymph from the left upper limb and accompanies the subclavian vein.

3. Truncus lymphaticus mammarius sinister - left lymphatic mammary trunk - collects lymph from the left mammary gland and goes behind the costal cartilages, accompanying v. mammaria interna.

In the right lymphatic duct, the length of which is 1-1.5 cm, flow into:

1. Truncus bronchomediastinalis - bronchomediastinal trunk - diverts lymph from the right lung (lymph flows from the left lung into the thoracic duct system), ascends and flows into the ductus lymphaticus dexter.

2. Truncus lymphaticus jugularis dexter - the right lymphatic jugular duct - collects lymph from the right half of the head and neck and accompanies the right internal jugular vein.

3. Truncus lymphaticus subclavius ​​dexter - the right lymphatic subclavian trunk - accompanies the right subclavian vein and collects lymph from the right upper limb.

4. Truncus mammarius dexter - right nipple lymphatic duct - diverts lymph along v.mammaria interna from the right mammary gland.

TOPOGRAPHY OF THE SUBMAXILLARY GLAND.

Submandibular gland, glandula submaxillaris, a paired formation located in the submandibular triangle. It is enclosed between two sheets of the own fascia of the neck. In appearance, it is a flattened-ovoid body weighing about 15 g. The boundaries of the saccus hyomandibularis and the submandibular gland are as follows: outside - the medial side of the body of the lower jaw; from inside - m. hyoglossus, m. styloglossus, from below - own fascia of the neck, subcutaneous fat, superficial fascia along with m. platysma myoideus and skin; the rear edge of the gland comes over m. mylohyoideus into the oral cavity and comes into contact with glandula sublingualis.

The duct of the submandibular gland, ductus submaxillaris (Wartoni), about 5 cm long, lies on m. mylohyoideus and goes forward along the medial side of the sublingual salivary gland to the frenulum of the tongue, frenulum linguae, where it opens on a special papilla - salivary sublingual meat, caruncula sublingualis salivalis.

In saccus hyomandibularis, in addition to the gland, there is also fatty tissue, lymph nodes, arterial and venous vessels and nerves. The main trunk a. passes through the thickness of this fascial sheath. maxillaris externa. It should be remembered that along the outer surface of the gland goes down v. facialis anterior, and on the inside - a. maxi]]ii§_externa. Thus, the gland is surrounded from the outside and from the inside by "large vessels; when removing it, it is necessary to bandage the vein lying on the gland,

The blood supply of the submandibular gland is carried out from the branches of a. maxillaris externa.

The "gland" is innervated from the ganglion submaxillare.

Lymph flows into 1-di submaxillares anteriores, posteriores et inferiores (Fig. 76).

NECK PART OF THE TRACHEA.

Below the larynx is the cervical part of the trachea, pars cervicalis tracheae. In the upper section, the trachea is surrounded in front and on the sides by the thyroid gland; behind it is the esophagus, separated from the trachea by loose connective tissue.

The entire tracheal tube is divided into two parts: cervical, pars cervicalis, and thoracic, pars thoracalis. The cervical part corresponds to the height of the VII cervical vertebra and at the upper thoracic inlet it passes into the thoracic one.

The direction of the cervical part of the trachea is oblique: it goes down and backwards at an acute angle. Therefore, in the upper section, the trachea is closest to the surface of the neck. At the height of the jugular notch of the sternum, the trachea lies at a depth of 4 cm; its first rings lie no deeper than 1.5–2 cm, and the bifurcation of the trachea at the level of the fifth thoracic vertebra is already at a depth of 6–7 cm. For this reason, the operation of the upper tracheotomy is technically easier than the operation of the lower tracheotomy. The latter presents difficulties also because in the lower part of the trachea is in close proximity to large vessels.

Rice. 76. Three variants of the position of the lymph nodes of the submandibular triangles in relation to the salivary submandibular gland.

1 - the main variant of the position - the presence of anterior, posterior and lower groups of lymph nodes - 59%; II - loose version of the position - the presence of five groups of lymph nodes (anterior, posterior, upper, lower and submandibular) - 25%; III - nodal variant of the position - the presence of only one group of lymph nodes in one of the corners of the submandibular triangle - 16% (according to A. Ya. Kulinich).

The trachea consists of 16-20 horseshoe-shaped cartilages, cartilagines tracheales, connected to each other by annular ligaments, ligamenta annularia. Behind the semirings of the trachea are connected by a movable membranous wall, paries membranaceus tracheae.

In front, the trachea is covered with a pretracheal fascia, fascia praetrachealis, associated with the middle and own fascia of the neck lying in front. The upper tracheal rings are covered by the isthmus of the thyroid gland. In the lower part of the cervical part of the trachea are the inferior thyroid veins, vv. thyreoideae inferiores, abundant venous unpaired thyroid plexus, plexus thyreoideus impar, and the left innominate vein often protrudes above the incisura juguli sterni, v. anonyma sinistra.

Therefore, when performing an inferior tracheotomy, it is necessary to divert the left innominate vein down. Bleeding during this operation is more significant than during the upper tracheotomy.

Behind the trachea is the esophagus.

From the sides to the upper part of the trachea, the lateral lobes of the thyroid gland are adjacent.

In the esophago-tracheal grooves formed by the esophagus and trachea, sulci oesophagotracheales, recurrent nerves, nn. recurrentes.

In the lower part of the cervical part of the trachea, the main neurovascular bundles of the neck are adjacent to it from the side.

It must be remembered that the isthmus of the thyroid gland is attached to the tracheal rings and has a single blood supply with it. For this reason, during the production of an upper tracheotomy in children, there are cases when, after moving the isthmus of the thyroid gland downwards, the blood supply to the cartilage of the trachea was disturbed and their necrosis occurred. Therefore, children prefer to do the lower tracheotomy.

Since the trachea is surrounded by loose tissue, significant displacements of the trachea and larynx are possible due to movements (for example, tilting) of the head.

NECK ESOPHAGUS.

The total length of the esophagus from its beginning to the cardia is on average 25 cm. In this case, the cervical part is 5 cm, the thoracic

- 17-18 cm and abdominal - 2-3 cm. It should be remembered that when inserting a gastric tube, the latter must be inserted 40 cm from the teeth, and then we can assume that the end of the tube has entered the stomach.

Skeletotopically, the entire esophagus extends from the penultimate cervical to the penultimate thoracic vertebra, m. e. from VI cervical to XI chest. The beginning of the esophagus also corresponds to the height of the cricoid cartilage.

The transition of the cervical part of the esophagus to the thoracic occurs at the level of the body of the III thoracic vertebra, since if you draw a horizontal plane at the height of the upper edge of the incisura juguli sterni, then this plane will pass through the III thoracic vertebra.

On its way, the esophagus forms three narrowings: the upper one - at the level of the VI cervical vertebra at the transition of the pharynx into the esophagus; the middle one - at the level of the intersection with the aorta (aortic narrowing) and the lower one - when it passes into the cardinal part of the stomach.

Syntopy of the cervical part of the esophagus. Due to the large amount of loose fiber surrounding the esophagus, the latter has the ability to move and stretch.

In front of the esophagus in the upper section is covered by the trachea, and on the sides of it by the posterior sections of the lateral lobes of the thyroid gland. Below the esophagus bends to the left, appears from under the left edge of the trachea and no longer lies in the median plane. For this reason, the cervical esophagus is always accessed from the left.

Behind the cervical part of the esophagus is located on the prevertebral fascia, fascia praevertebralis, which in turn lies on the spine long muscles of the neck and head (m. longus capitis and m. longus colli). Here, in the thickness of the prevertebral fascia, sympathetic border trunks lie, and on the left, the truncus sympathicus is closer to the esophagus than on the right, which again is explained by the deviation of the esophagus to the left.

From the sides to the cervical part of the esophagus, the main neurovascular bundles of the neck are adjacent at a distance of 1–2 cm. In connection with the deviation of the esophagus to the left on this side, it is closer to the carotid vessels than on the right. Laterally, the arch of the inferior thyroid artery is adjacent to the esophagus, a. thyreoidea inferior.

The blood supply to the cervical part of the esophagus is carried out by branches a. thyreoidea inferior.

Innervation - branches of the vagus nerve.

OPERATIVE ACCESS TO THE NECK ORGANS.

All currently used operational approaches to various organs of the neck are divided into three groups: longitudinal, transverse and combined.

Longitudinal accesses include:

Rice. 77. Operative incisions on the neck.

1 - upper oblique section; 2 - cross section of Eremich; 3 - upper median section; 4 - cross section for strumectomy; 5 - lower oblique section; (c) Tsang section.

Rice. 78. Operative incisions on the neck.

1 - Z-shaped section of Dyakonov; 2 - T-shaped section of the Crile; 3 - rear oblique section; 4, – Alexander section.

Straight cuts

1. Upper median incision - to expose the larynx and the initial part of the trachea; used in the production of upper tracheotomy, conicotomy, laryngofissure, laryngectomy.

2. Lower median incision - from the cricoid cartilage to the jugular notch; used for lower tracheotomy.

Oblique cuts

1. Upper oblique incision - is carried out along the anterior edge of the sternocleidomastoid muscle along its upper third; used for ligation of the external and common carotid arteries and internal jugular vein, as well as for cervical sympathectomy. The incision is made within the trigonum caroticum.

2. The lower oblique incision is made along the anterior edge of the lower half of the sternocleidomastoid muscle within the trigonum omotracheale. It is used for ligation of carotid vessels in the middle part of the neck, as well as for cervical sympathectomy.

3. Oblique incision along Tsang - is carried out between the legs of the sternocleidomastoid muscle to expose within the small supraclavicular fossa, fossa supraclavicularis minor, common carotid artery.

4. Posterior oblique incision - is carried out along the posterior edge of the sternocleidomastoid muscle - is used for cervical sympathectomy and for access to the esophagus on the left (Fig. 77 and 78).

Cross sections

They are used at different heights of the neck to expose certain organs.

1. Transverse incision from the angle of the lower jaw to the midline of the neck - used for lateral pharyngotomy, pharyngotomia lateralis.

2. Cross section of Eremich - is carried out between the inner edges of the sternocleidomastoid muscles at the level of the hyoid bone; used to expose the pharynx above the hyoid bone (pharyngotomia suprahyoidea).

3. Cross section through eminentia eartilaginis thyreoideae; it is also carried out from one inner edge of the sternocleidomastoid muscle to the other; used to expose the pharynx below the hyoid bone, pharyngotomia subhyoidea.

4. Transverse incision for strumectomy - is carried out along the largest bulge of the tumor in the middle parts of the neck.

5. Transverse incision in the supraclavicular region to expose and ligate the subclavian artery and brachial plexus; is carried out on the transverse finger above and parallel to the clavicle.

Combined cuts

1. Dyakonov's Z-shaped incision - is carried out under the edge of the lower jaw, then along the anterior edge of the sternocleidomastoid muscle and then parallel to the collarbone; used to expose the deep organs of the neck.

2. Venglovsky incision - is carried out along the anterior edge of the sternocleidomastoid muscle, two transverse incisions are added to it, directed backwards and crossing this muscle above and below. Access is extensive and convenient for removal of lymph nodes and large tumors.

3. Kütner's incision - starts from the posterior edge of the sternocleidomastoid muscle 2 cm below the mastoid process, goes forward with the intersection of m. sternocleidomastoideus and along the anterior edge of the muscle is brought to the jugular notch. It is used for extirpation of lymph nodes. In this case, the muscle leans outward and the upper sections of the neck are exposed.

4. Dekarvin's incision - is carried out along the anterior edge of the sternocleidomastoid muscle, then wrapped back along the upper edge of the clavicle. With this access, the lower sections of the neck are exposed.

5. Disyansky incision - is also carried out along the anterior edge of the sternocleidomastoid muscle from the level of the hyoid bone upwards to the angle of the lower jaw, then it wraps arched backwards, crosses m. sternocleidomastoideus and descends along the posterior edge of this muscle. It is used to expose the organs of the upper parts of the neck.

6. Crile's incision - a T-shaped incision - is used in the operation of removing the entire complex of superficial and deep lymph nodes of the neck with malignant tumors of the tongue or lip in advanced cases with concomitant excision of the sternocleidomastoid muscle (in order to remove the superficial lymphatic tract and lymph nodes ) and the internal jugular vein (for the purpose of extirpation of the jugular lymphatic duct along with deep cervical lymph nodes). An incision is made under the edge of the lower jaw, then an additional incision is made from the middle of this incision down towards the middle of the clavicle. The incision creates a very extensive access to the deep organs of the neck.

Carrying out a comparative assessment of surgical access to the organs of the neck, it should be noted that the longitudinal incisions are slightly traumatic, but leave rough scars. Transverse incisions on the cosmetic side are better, since the scar is hidden in the natural folds of the skin, but they create a cramped surgical field.

Of the combined methods, extensive access to deep organs creates a Dyakonov incision. The same can be said about the Venglovsky section. The Kütner incision is convenient for exposing the upper parts of the neck, the Deckerven incision is for exposing the organs of the lower parts of the neck. The Venglovsky incision is especially convenient for the patient with a short neck. When accessing Lisyansky, one should beware of injuring n. accessorius (Willisii) (Fig. 79, 80, 81, 82, 83, 84).

Back of the neck

The basis of the back of the neck, regio colli posterior s. cervicis, or nuchal region, regio nuchae, is a powerful system of muscles arranged in four layers.

Borders: from above - the nuchal or posterior cervical region is limited by a large occipital eminence, protuberantia occipitalis externa, and horizontally running upper you are other lines, lineae nuchae superiores, from below the border is a horizontal line passing through the spinous process of the VII cervical vertebra; from the sides, the border between the anterior and posterior regions of the neck runs along the outer edge of the trapezius muscle; in front, the region is separated from the regio colli anterior by a frontally running dense fascia, which is a continuation of the fascia colli propria, as well as by the posterior sections of the cervical spine.

LAYERS OF THE BACK OF THE NECK.

1. Derma - skin - is very thick and dense.

2. Panniculus adiposus - subcutaneous fatty tissue - it contains superficial vessels and nerves. In the upper part of the neck, subcutaneous branches of a. occipitalis; in the lower - ramifications of the ascending branch of the transverse artery of the neck, ramus ascendens a. transversae colli. The main trunk of this artery passes between m. splenus and m, levator scapulae, its skin branches penetrate the trapezius muscle and go under the skin. The outflow of venous blood from the surface layers occurs along v. cervicalis superficialis descending along the sides of the neck and flowing into the v. jugularis interna.

Rice. 79 Operative incisions on the neck.

1 – arched Lazrisyansky section; 2 – angular section of Deckervain.

Rice. 80. Operative incisions on the neck.

1 – fenestrated section of Venglovsky; 2 – Alshevsky-Styurz section for outcrop n. phrenicus 3 - transverse incision for lateral pharyngotomy.

Rice. 81. Cuts on the neck.

Rice. 82. Online accessto the first rib along Coffey-Antelava

Rice. 83. Sections for outcrop n.phrenicus

1 - Alshevsky-Styurz; 2 - parallel m. sternocleidomastoideus, 3 - Alexander; 4 - Fruchet, 5 - Kutomanova; 6 - Lilienthal; 1 - Berara (according to N.V. Antelava).

3. Fascia superficialis - superficial fascia.

4. Lamina superficialis fasciae colli propriae - the surface plate of the own fascia of the neck - is somewhat denser than the previous one.

Rice. 84. Operative access to neurovascular bundles.

A. Outcrop a. carotis communis: 1 – m. sternocleidomastoideus; 2-v. jugularis interims; 3-n. vagus; 4-a. carotis communis dextra. B. Outcrop a. subclavia: 1 - m. omohyoideus; 2 - plexus brachialis; 3 - platysma myoides; 4-a. subclavia 5–m. scalenus anterior; 6-n. phrenicus. C. Outcrop a. axillaris: 3 - plexus brachialis; 4-a. axillaris; 5-v. axillaris. D. Outcrop a. mammaris interims: 6 - m. pectoralis major; 7 - m. intercostalis interna; 8-a. mammaris interna.

5. M. trapezius - the trapezius muscle - belongs to the first layer of the posterior muscle group of the neck. It begins on the neck along the superior nuchal line, linea nuchae superior, protuberantia occipitalis externa, and from the spinous processes of the cervical and thoracic vertebrae; the trapezius muscle is attached to the clavicle and acromial process of the scapula, as well as to the spina scapulae. Innervated by n. accessorius.

6. Lamina profunda fasciae colli propriae - a deep plate of the own fascia of the neck - lines the trapezius muscle from the inside.

7. The second muscle layer - consists of the following muscles:

1) mm. splenii, capitis et cervicis - the belt muscle of the head and neck - occupies the medial part of the neck under the trapezius muscle.

2) M. levator scapulae - the muscle that lifts the scapula - is located in the same layer outward from the previous one.

Under these muscles in the lower part of the neck lie the initial sections of the rhomboid and serratus posterior muscles.

3) mm. rhomboidei, major et minor - small and large rhomboid muscles and under them;

4) M. serratus posterior superior - serratus posterior superior muscle. 8. The third layer of muscles is composed of long dorsal muscles: 1) Mm. semispinales, capitis et cervicis - the floor of the spinous muscles of the head and neck and outward from them.

Rice. 85. Triangle, vessels and nerves of the nuchal region.

1-n. occipitalis major; 2-n. suboccipitalis; 3 - trigonum nuchae superior; 4 - m. obliquus capitis superior; 5 – a. vertebralis; 6 - m. obliquus capitis inferior; 7 - trigonum nuchae inferior; 8-a. occipitalis; 9 - m. sternocleidomastoideus; 10 - m. trapezius.

2) mm. longissimi capitis et cervicis - long muscles of the head and neck.

9. The fourth layer of muscles is formed by several small muscles:

1) M. rectus capitis posterior major - the large posterior rectus muscle of the head - is located medially.

2) M. rectus capitis posterior minor - a small posterior rectus muscle of the head - lies under the previous muscle.

3) M. obliquus capitis superior - the upper oblique muscle of the head - stretches from the lower nuchal line to the transverse process of the atlas; lies outside of the large rectus capitis.

4) M. obliquus capitis inferior - the lower oblique muscle of the head - is stretched in an oblique direction between the spinous process of the epistrophy and the transverse process of the atlas. The described muscles take part in the formation of the suboccipital triangle.

5) M. multifidus - a multifidus muscle - is a small muscle bundles that lie deeper than all the other back muscles of the neck.

10 Pars cervicalis columnae vertebralis - the cervical part of the spinal column - consists of seven cervical vertebrae. Their spinous processes are connected by a continuous cord - vyuchny

ligament, lig. nuchae; yellow ligaments, ligamenta flava, are stretched between the arches of the vertebrae.

The occipital bone is connected to the atlas by the atlanto-occipital membrane, membrana atlantooccipitalis; atlas with epistrophy - with the help of lig. atlantoepistrophica.

TRIANGLES OF THE OUTPUT AREA.

1. Trigonum nuchae superior - the upper nuchal triangle - is limited by the following three muscles: from the inside m. rectus capitis posterior major; from the outer upper side - m. obliquus capitis superior, from the outer lower side - m. obliquus capitis inferior.

In the transverse direction, the triangle is crossed by the posterior arch of the atlas, arcus posterior atlantis. Above the latter lies the transverse part of the vertebral artery a. vertebralis. In the same triangle, the suboccipital nerve appears, n. suboccipitalis.

2. Trigonum nuchae inferior - the lower pull-out triangle - is located below the previous one. Its borders: from above - obliquely running lower oblique muscle of the head, m. obliquus capitis inferior; outside - long muscle of the head, m. longus capitis; from the inside - the semispinous muscle of the neck, m. semispinalis cervicis.

In this triangle, n comes out. occipitalis major, which, having rounded m. obliquus capitis inferior, ascends to the occipital region of the head (Fig. 85–86).

The blood supply to the deep sections of the back of the neck is carried out from the following sources:

1. A. occipitalis - occipital artery - passing sulcus a. occipitalis, on the medial surface of the mastoid process perforates the initial sections of mm. splenii capitis et cervicis and goes to the back of the neck between m. trapezius and m. sternocleidomastoideus. On its way, it gives branches to the muscles of the upper neck.

2. A. transversa colli - the transverse artery of the neck - passes between the fascicles of the brachial plexus, crosses m. scalenus medius, goes outward and lies under m. levator scapulae. Here it is divided into two branches: ascending, ramus ascendens, and descending, ramus descendens. The first branch goes up, located between m. levator scapulae and m. splenius cervicis, and supplies these muscles with blood, as well as m. trapezius.

Rice. 86. The nuchal region of the neck.

1-a. occipitalis 2 - m. obliquus capitis superior; 3-n. occipitalis major; 4 - m. obliquus capitis inferior; 5 – a. cervicalis profunda.

3. A. cervicalis profunda - the deep artery of the neck rises and penetrates between the transverse process of the VII cervical vertebra and the I rib and lies between m. semispinalis cervicis and m. semispinalis capitis.

On the way, it gives off branches that supply blood to the deep muscles of the back of the neck.

4. A. vertebralis - the vertebral artery - passes through the holes in the transverse processes of the cervical vertebrae, foramina transversaria. Upon exiting the foramen transversarium II of the vertebra, the artery deviates inwards and, having passed the foramen transversarium atlantis, lies transversely in sulcus a. vertebralis above the posterior arch of the atlas. Further, the artery pierces the membrana atlantooccipitalis and leaves through the foramen magnum into the cranial cavity.

Thus, the vertebral artery first rises vertically, then takes a horizontal position, then again goes up and goes into the cranial cavity through the foramen magnum.

Venous outflow is carried out mainly through the veins of the same name and into the external jugular vein v. jugularis externa.

The nerves of the nuchal region are represented by metamerically running posterior branches of the cervical nerves, rami posteriores nervorum cervicalium.

The first of them is highlighted under the name of the suboccipital nerve, n. suboccipitalis, and innervates the small deep muscles of the neck with motor branches: mm. recti capitis posterior, major et minor, mm. obliqui capitis, superior et inferior.

The second cervical nerve is a large occipital, n. occipitalis major, sensitive in nature, extends within the lower nuchal triangle and rises to the occipital region.

Lymph outflow from the nuchal region occurs in two directions: from the upper parts of the neck - upwards, to the occipital lymph nodes, 1-di occipitales, and from the middle and lower parts of the region - to the axillary lymph nodes, 1-di axillares. In addition, some lymphatic vessels of the deep regions, heading forward - to the anterior region of the neck, pour lymph into the system of the jugular lymphatic ducts.

SUBOCPITAL PUNCTURE.

If it is necessary to penetrate the cerebellar-spinal cistern (for diagnostic purposes, for the administration of drugs or to divert cerebrospinal fluid, liquor cerebrospinalis, with an increase in intracranial pressure, for ventriculography), a suboccipital puncture is often resorted to. In this case, it is necessary to clearly imagine the anatomical conditions, since the intervention is fraught with the danger of injuring the medulla oblongata or cerebellum.

Cisterna cerebellomedullaris, the cerebellar-spinal cistern, occurs at different depths, from 3.5 to 8 cm (Voznesensky, 1940). A straight transverse line is drawn connecting the tops of the mastoid processes of both sides. A long needle is injected strictly in the middle of the indicated line; the direction of the needle is obliquely upwards. Initially, the end of the needle rests against the posterior edge of the large occipital foramen, then, gradually changing the angle, it is injected steeper until the needle slips off the edge of the large occipital foramen and rushes forward without resistance. Having met the atlanto-occipital membrane, membrana atlantooccipitalis, on the way, the surgeon feels a slight resistance (like piercing parchment). After its puncture, the mandrin is removed, while the cerebrospinal fluid flows out through the lumen of the needle.

Ulcers and phlegmons of the neck.

When analyzing the fascial apparatus of the neck, we have already met with the main types of phlegmon of the neck.

These phlegmons can be schematically classified as follows.

There are superficial and deep phlegmons on the neck. The first occur when injured or with minor damage to the skin; the latter are most often formed as a result of purulent fusion of deep lymph nodes with lymphadenitis.

The spread of pus in abscesses and phlegmon of the neck can occur in the following directions:

1) with superficial phlegmon - down to the chest wall, where pus is concentrated in the subcutaneous fat;

2) with intrafascial phlegmon (between the sheets of the superficial fascia) - down to the mammary gland, sometimes causing inflammation;

3) with subfascial phlegmon - down behind the fascia into the retrothoracic space (gives abscesses behind the mammary gland);

4) with phlegmon of the vagina of the sternocleidomastoid muscle, a sausage-like swelling of this muscle occurs (with the Bezold form of mastoiditis);

5) with phlegmon of the supraclavicular and supraclavicular spaces, pus is concentrated between the fascia colli propria and fascia colli media; the clinical picture is characterized by an inflammatory collar over the sternum and collarbone; such abscesses usually occur due to osteomyelitis of the sternum or purulent myositis of the sternocleidomastoid muscle;

6) phlegmon of the floor of the mouth is often complicated by the spread of pus into the peripharyngeal space or into the posterior maxillary fossa along the vessels; in these cases, the vessel wall may melt and threatening bleeding may suddenly open;

7) phlegmon spatium praeviscerale result from damage to the trachea or larynx; the process can be complicated in these cases by anterior mediastinitis.

8) phlegmon spatium retroviscerale occurs when the esophagus is damaged by foreign bodies; complicated by posterior mediastinitis;

9) abscesses behind the fascia praevertebralis occur with tuberculous lesions of the cervical vertebrae; at the same time, the natechnik is usually opened and opened within the outer cervical triangle.

FISTULAS OF THE NECK.

There are median and lateral fistulas of the neck.

According to the theory of R. I. Venglovsky accepted at the time, median fistulas of the neck develop as a result of non-closure of a special embryonic duct that connects the thyroid gland with the root of the tongue (ductus thyreoglossus).

In the process of development, a long cord is formed between the isthmus of the thyroid gland and the foramen coecum of the tongue, which does not have a lumen - tractus thyreoglossus. The epithelial cells that form this cord are atrophied particles of the thyroid gland. These cells form microscopic cysts that secrete a clear fluid. As the tractus develops, the thyreoglossus breaks into two parts of different lengths. If the amount of released clear fluid becomes significant, median fistulas are formed at different levels of the neck. When suppurated, a mucopurulent liquid is released from them.

Palliative treatment of fistulas (iodine administered to cause obliteration of the remnants of the ductus thyreoglossus) does not give results, and only a radical excision of the fistula guarantees long-term results.

Lateral fistulas are explained by non-closure of the thymus-pharyngeal duct, ductus thymopharyngeus, existing in the embryonic period. The remnants of this duct, becoming inflamed, lead to the development of lateral fistulas of the neck, located, as a rule, somewhere along the anterior edge of the sternocleidomastoid muscle. The fistulous tract usually begins behind the tonsil and extends downward, opening most often near the jugular notch.

Elimination of lateral fistulas of the neck is also achieved only by surgery.

NECK RIBS.

Cervical ribs, considered as an anomaly of development, are not uncommon. In women, cervical ribs are found twice as often as in men. Usually they are associated with the VII cervical vertebrae, less often with the VI. Their length, as a rule, does not exceed 5-6 cm. These ribs most often do not attach to the sternum and end freely. Located above the subclavian artery and brachial plexus, the cervical ribs cause a number of vascular and nervous disorders due to pressure on the vessels and nerves underlying them. When carrying weights on the shoulder, the subclavian vessels or the brachial plexus can be damaged by the protruding end of the rib.

Significant disorders caused by the cervical ribs require in all cases their surgical removal.

Neck BordersNECK BORDERS
Upper - lower edge of the lower jaw, apex
mastoid process and superior nuchal line to
external occipital protrusion;
Lower - along the jugular notch of the sternum, upper
edge of the clavicle to the acromial process of the scapula and
spinous process of the VII cervical vertebra.
A line drawn from the mastoid
trapezius muscle to the acromion
process of the scapula, divides the area into 2 sections.

Departments of the neck

FRONT
Neck organs (larynx, trachea,
pharynx, esophagus, thyroid
and parathyroid glands)
Vessels
(sleepy
arteries,
branches of the subclavian artery
internal jugular vein,
jugular
lymphatic
trunk)
Nerves (cervical and brachial)
plexus,
wandering
nerves,
cervical
Department
sympathetic trunk).
REAR COMPARTMENT
Vynaya
region
With
located
there
extensor muscles.
SECTIONS OF THE NECK

Layered topography of the back of the neck

LAYERED TOPOGRAPHY OF THE BACK REGION
NECK
Leather
PZhK
Fascia
- superficial
- own (superficial and deep sheets)
muscles
- superficial layer (trapezius muscle)
- deep (belt muscles of the head and neck, muscles,
levator scapulae, upper edge of the lesser
diamond-shaped
muscle,
muscle,
rectifier
torso,
own muscles of the spine,
suboccipital muscles.

Blood supply to the back of the neck

BACKGROUND SUPPLY
NECK
The blood supply is carried out by the branches of the external
sleepy
(occipital,
rear
ear)
and
subclavian (transverse artery of the neck,
vertebral artery, deep neck artery
branch of the costal-cervical trunk) arteries.
Venous drainage is carried out through the external
jugular vein and veins of the same name with
arteries into the internal jugular vein.
Lymphatic drainage is carried out from above
down and laterally, lymph flows
in
occipital, deep cervical lymphatic
nodes.

Innervation of the back of the neck

INNERVATION OF THE BACK OF THE NECK
Suboccipital muscles - suboccipital nerve;
The skin and muscles of the occiput - the greater occipital
nerve;
The skin of the back of the neck - lesser occipital
cervical plexus nerve, transverse nerve
brachial plexus;
Trapezius muscle - XI pair of cranial nerves;
Muscles of the back of the neck - short branches
C3-C7;
Muscles that lift the scapula, rhomboid
muscles - dorsal nerve of the scapula.

Neck Triangles

MEDIAL TRIANGLE
Top bounded by bottom
the edge of the lower jaw;
Medially
front
median line;
Lateral - anterior
edge
sternocleidomastoid muscle.
Projection of organs: larynx,
trachea,
thyroid
and
parathyroid,
pharynx, esophagus.
LATERAL TRIANGLE
Front - rear end
sternocleidomastoid muscle;
Behind
–
edge
trapezius muscle;
Bottom - top edge
clavicle;
Projection of organs: external
brachial and cervical nerve
plexus,
supraclavicular
lymphatic
nodes,
external jugular vein.
NECK TRIANGLES

10. Triangles and rectangles of the neck

TRIANGLES AND RECTANGLES OF THE NECK
Chin
triangle
(unpaired)
Rectangle
(sternocleidomastoid region).

11.

MEDIAL
TRIANGLE
Submandibular
Sleepy
scapular-tracheal
LATERAL
TRIANGLE
scapular-clavicular
Scapular-trapezoid

12. Submandibular triangle

SUBCANDIBLE TRIANGLE
Borders: bottom edge
bottom
jaw,
bellies
digastric
muscles;
Projection:
submandibular
salivary
glands
and
lymphatic
nodes,
facial artery.

13. Sleepy triangle

SLEEPING TRIANGLE
Borders: posterior belly digastric
muscles, anterior edge of the sternocleidomastoid muscle and upper abdomen
scapular-hyoid muscle;
Projection: thyroid and parathyroid
glands, stellate ganglion, SNP of the neck - common
carotid artery, internal jugular vein and
nervus vagus.

14.

15. Scapular-tracheal triangle

SCOOP-TRACHEAL TRIANGLE
Borders:
anterior edge of the sternocleidomastoid muscle, superior
abdomen of the scapular-hyoid muscle
and the midline of the neck;
Projection:
lower part of the throat
isthmus of the thyroid gland and trachea.

16. Scapular-clavicular triangle

Scapular-clavicular triangle
Borders:
clavicle, lower abdomen
scapular-hyoid muscle, posterior
edge
sternocleidomastoid
muscles.
Projection:
supraclavicular l/u, SNP
lateral triangle of the neck -
brachial plexus, subclavian
artery and vein.

17. Scapular-trapezoid triangle

SPADE-TRAPEZIOID TRIANGLE
Borders:
edge of the trapezius muscle
lower abdomen scapular-hyoid
muscles, posterior edge of the sternocleidomastoid muscle.
Projection: external jugular vein,
superficial cervical l / y, branches
cervical plexus and accessory nerve.

18. Submental triangle

CHIN TRIANGLE
Borders:
front
bellies
digastric muscle and the edge of the lower
jaws.
Projection:
sublingual
salivary
glands and tongue.

19. Rectangle Neck

RECTANGLE NECK
Borders:
the edges
sternocleidomastoid muscle, which begins
two legs from the jugular notch of the sternum
and sternal end of the clavicle and is attached
to the mastoid process.
Projections:
outdoor
jugular
vein,
external jugular artery, l / y, cervical
plexus, SNP - common carotid artery,
internal jugular vein, vagus
nerve.

20. Layered topography of the anterior region of the neck

LAYERED TOPOGRAPHY OF THE ANTERIOR
NECK AREAS
Leather
PZhK
Fascia of the neck
- superficial
- own
- scapular-clavicular
- intracervical
- prevertebral
Neck muscles
- superficial (subcutaneous muscle of the neck, sternocleidomastoid, digastric, stylohyoid, maxillohyoid,
geniohyoid, sternohyoid, sternothyroid, thyrohyoid, scapular-hyoid)
- deep (long muscles of the head, neck, anterior and lateral
straight, front, middle and back stairs).

21.

22. Blood supply to the anterior region of the neck

BLOOD SUPPLY OF THE ANTERIOR NECK
Branches of the external carotid artery
- superior thyroid artery - thyroid gland,
larynx,
sublingual
bone,
sternocleidomastoid muscle;
- lingual artery - tongue, sublingual salivary gland,
muscles of the floor of the mouth;
- facial artery - submandibular salivary gland, muscles,
lying above and below the hyoid bone;
- ascending pharyngeal artery - muscles of the pharynx, deep
neck muscles;
Branches of the subclavian artery
- thyroid trunk - organs, muscles of the neck, spinal cord;
- Costo-cervical trunk - deep muscles of the neck.

23.

24.

INNERVATION OF THE ANTERIOR NECK
Trigeminal nerve (V pair) - mandibular nerve -
maxillohyoid muscle and anterior abdomen
digastric muscle;
Facial nerve (VII pair) - posterior belly of the digastric
muscles, subcutaneous muscle of the neck;
Glossopharyngeal nerve (IX pair) - stylopharyngeal muscle,
mucous membrane of the pharynx;
Vagus nerve (X pair) - motor branches -
larynx, pharynx, esophagus, sensitive - mucous
membrane of the neck organs (except the pharynx), parasympathetic
- smooth muscles and glands of the neck organs;
Accessory nerve (XI pair) sternocleidomastoid muscle and glands of the neck organs;
Hypoglossal nerve (XII pair) - through the cervical loop
neck muscles below the hyoid region.

25. Innervation of the anterior region of the neck

INNERVATION OF THE ANTERIOR NECK
Motor nerves - to the muscles of the neck;
Sensory nerves:
transverse
nerve
neck
–
leather
anterolateral
surfaces
neck
from
chin to collarbone;
- greater auricular nerve - auricle
anterior, external auditory canal, upper
departments of the lateral surface of the neck;
- supraclavicular nerve - skin of the clavicles and lower
sections of the lateral surface of the neck.

The neck is an area whose upper border runs along the lower edge of the lower jaw, the apex of the mastoid process and the upper nuchal line. The lower border corresponds to the jugular notch of the sternum, the upper edges of the clavicles and the line connecting the acromial process of the scapula with the spinous process of the VII cervical vertebra.

In the anterior part of the neck, separated from the posterior frontal plane, there are organs - the trachea, esophagus, thyroid gland, neurovascular bundles, the thoracic duct is located in the cervical vertebrae passing through the transverse processes. In the back of the neck there are only muscles enclosed in dense fascial cases and adjacent to the cervical vertebrae.

Neck triangles. By a horizontal plane drawn at the level of the body of the hyoid bone, the anterior neck is divided into suprahyoid and infrahyoid regions. The muscles located in the suprahyoid region form the bottom of the oral cavity, in this area three triangles are distinguished: unpaired submental, the sides of which are formed by the hyoid bone and two anterior bellies of the digastric muscles; paired right and left submandibular triangles formed by the lower edge of the lower jaw and both bellies (anterior and posterior) of the digastric muscles. The sublingual region is divided by the median line into the right and left sides. On each side, two large triangles and a rectangle are distinguished.

The medial triangle is formed by the median line, the posterior belly of the digastric muscle, and the anterior edge of the sternocleidomastoid muscle; lateral triangle - the posterior edge of the sternocleidomastoid muscle, the upper edge of the clavicle and the lateral edge of the trapezius muscle. Between these triangles is a rectangle - the sternocleidomastoid region. In the medial triangle, two triangles are formed - the scapular-tracheal and the scapular-hyoid (carotid triangle), since the common carotid artery and its bifurcation are located within it.

Fascia of the neck. The clearest description was given by Academician V. N. Shevkunenko, who proposed a classification based on a genetic approach to study.

By origin, all fasciae are divided into three groups:

1) fasciae of connective tissue origin, formed as a result of compaction of loose connective tissue and fiber around muscles, blood vessels and nerves;

2) fascia of muscular origin, formed at the site of reduced muscles or flattened and stretched tendons (aponeurosis);

3) fasciae of coelomic origin, which are formed from the inner lining of the primary embryonic cavity or from the reducing sheets of the primary mesentery.

In this regard, 5 fasciae are distinguished on the neck. The first fascia of the neck - the superficial fascia is of muscular origin, it is found in all parts of the neck. On the front surface of the neck, this fascia can be stratified by accumulations of adipose tissue into several plates. In the anterolateral sections, the superficial fascia forms a case for the subcutaneous muscle and, together with its fibers, continues to the face, and below to the subclavian region. In the back of the neck, numerous connective tissue bridges stretch from the superficial fascia to the skin, dividing the subcutaneous adipose tissue into numerous cells. This feature of the structure of the subcutaneous fat leads to the development of carbuncles in this zone (sometimes), accompanied by extensive necrosis of the fiber, reaching the fascial muscle cases. The second fascia of the neck - a superficial sheet of its own fascia - in the form of a dense sheet surrounds the entire neck, including both its anterior and posterior sections. Around the submandibular gland, sternocleidomastoid, and trapezius muscles, this fascia splits and forms a sheath. The spurs of the second fascia extending in the frontal direction are attached to the transverse processes of the cervical vertebrae and anatomically divide the neck into two sections: anterior and posterior. Due to the presence of a dense fascial plate, purulent processes develop in isolation, either only in the anterior or only in the posterior parts of the neck. The third fascia (deep sheet of the own fascia of the neck) is of muscular origin. It is a thin but dense connective tissue plate stretched between the hyoid bone and the collarbone. At the edges, this fascia is limited by the scapular-subclavian muscles, and near the midline by the so-called "long muscles of the neck" (sternohyoid, sternothyroid, sublingual thyroid) and resembles a trapezium (or sail) in shape. Unlike the 1st and 2nd fascia, which cover the entire neck, the 3rd fascia has a limited length and covers only the scapular-tracheal, scapular-clavicular triangles and the lower part of the sternocleidomastoid region. The fourth fascia (intracervical) is a derivative of the tissues that form the lining of the primary cavity. This fascia has two sheets: parietal and visceral. The visceral layer covers the organs of the neck: the trachea, esophagus, thyroid gland, forming fascial capsules for them. The parietal layer surrounds the entire complex of organs of the neck and the neurovascular bundle, consisting of the common carotid artery, the internal jugular vein, and the vagus nerve. Between the parietal and visceral sheets of the 4th fascia, anterior to the organs, a slit-like cellular space is formed - previsceral (spatium previscerale, spatium pretracheale). Behind the 4th fascia of the neck, between it and the fifth fascia, there is also a layer of fiber - the retrovisceral (spatium retroviscerale) space. The fourth fascia, surrounding the organs of the neck, topographically does not go beyond the median triangle of the neck and the region of the sternocleidomastoid muscle. In the vertical direction, it continues upward to the base of the skull (along the walls of the pharynx), and descends downward along the trachea and esophagus into the chest cavity, where its analogue is the intrathoracic fascia. From this follows an important practical conclusion about the possibility of spreading (formation of a streak) of a purulent process from the cellular spaces of the neck into the tissue of the anterior and posterior mediastinum with the development of anterior or posterior mediastinitis. The fifth fascia (prevertebral) covers mm. longi colli lying on the anterior surface of the cervical spine. This fascia is of connective tissue origin. Continuing in the lateral direction, it forms a case (fascial sheath) for the brachial plexus with the subclavian artery and vein and reaches the edges of the trapezius muscles. Between the 5th fascia and the anterior surface of the spine, a bone-fibrous sheath is formed, filled mainly with the long muscles of the neck and surrounding them with loose fiber.

Fascial cases often serve as pathways for the spread of hematomas in case of injuries of the blood vessels of the neck and the spread of purulent streaks in case of phlegmon of various localization. Depending on the direction of the fascial sheets, the formation of spurs and connections with bones or neighboring fascial sheets, the cellular spaces of the neck can be divided into two groups: closed cellular spaces and open cellular spaces. Closed cellular spaces are represented by the following formations. Suprasternal interaponeurotic space located between the 2nd and 3rd fascia of the neck; case of the submandibular gland, formed by splitting the 2nd fascia of the neck, one of the sheets of which is attached to the lower edge of the jaw, the second to the linea mylohyoidea; case of the sternocleidomastoid muscle (formed by splitting the 2nd fascia). Unclosed cellular spaces include: the previsceral space located between the parietal and visceral sheets of the 4th fascia in front of the trachea from the level of the hyoid bone to the jugular notch of the sternum (at the level of the sternum handle by a fragile transverse septum, separated from the anterior mediastinum); retrovisceral space (located between the visceral sheet of the 4th fascia, surrounding the pharynx, trachea and esophagus, and the 5th fascia, continues into the posterior mediastinum); fascial sheath of the neurovascular bundles of the neck, formed by the parietal sheet of the 4th fascia (at the top it reaches the base of the skull, and at the bottom it leads to the anterior mediastinum); fascial sheath of the neurovascular bundle, formed in the lateral triangle of the neck by the 5th fascia (penetrates into the interstitial space and then goes to the subclavian and axillary regions).

The main principle in the treatment of neck abscesses is a timely incision that provides a wide opening of all pockets in which pus can accumulate. Depending on the localization of the purulent focus, various incisions are used for its drainage. With phlegmon of the suprasternal interaponeurotic cellular space, it is advisable to make an incision along the midline from the jugular notch of the sternum from the bottom up. If the process extends into the supraclavicular interaponeurotic space, counter-opening can be applied by making a transverse incision above the clavicle with the introduction of drainage from the outer edge of the sternocleidomastoid muscle. In severe cases, it is possible to cross one of the legs (sternal or clavicular) of the muscle. With phlegmon of the sac of the submandibular gland, the incision is made parallel to the edge of the lower jaw, 3-4 cm below. After dissection of the skin, subcutaneous tissue and the 1st fascia of the neck, the surgeon penetrates deep into the gland case in a blunt way. The cause of such phlegmon may be carious teeth, the infection of which penetrates into the submandibular lymph nodes. With submental phlegmon, a median incision is made between the two anterior bellies of the digastric muscle. With phlegmon of the vascular sheaths, the incision is made along the anterior edge of the sternocleidomastoid muscle or above the clavicle, parallel to it, from the posterior edge of the sternocleidomastoid muscle to the anterior edge of the trapezius. Phlegmon of the vagina of the sternocleidomastoid muscle is opened with incisions along the anterior or posterior edge of the muscle, opening a sheet of the 2nd fascia, which forms the anterior wall of the muscle sheath. Phlegmon of the previsceral space can be drained by a transverse incision over the jugular notch of the sternum. Phlegmons of the retrovisceral space are opened with an incision along the inner edge of the sternocleidomastoid muscle from the notch of the sternum to the upper edge of the thyroid cartilage. The pharyngeal abscess is opened through the mouth in the zone of greatest fluctuation, with the patient in a sitting position.

Topography and access to the carotid arteries

The common carotid artery is the main artery located in the neck. She, along with the vagus nerve and the internal jugular vein in the lower half of the neck, is projected into the regio sternocleidomastoideus. Slightly below the level of the upper edge of the thyroid cartilage, the artery emerges from under the anterior edge of the muscle and divides into the internal and external carotid arteries. The bifurcation of the artery is located at the level of the notch of the thyroid cartilage and is projected in the carotid triangle of the neck. Within this triangle, both the common carotid artery and both of its branches are most accessible for exposure. The classical projection line of the common carotid artery is drawn through points, the upper of which is located midway between the angle of the lower jaw and the apex of the mastoid process, the lower one corresponds to the sternoclavicular joint on the left, and is located 0.5 cm outward from the sternoclavicular joint on the right. To verify (identify) the external and internal carotid arteries, the following features are used: the internal carotid artery is located not only posteriorly, but, as a rule, also lateral (outward) from the external carotid; branches depart from the external carotid artery, while the internal carotid artery does not give branches on the neck; temporary clamping of the external carotid artery above the bifurcation leads to the disappearance of pulsation a. temporalis superficialis and a. facialis, which is easily determined by palpation.

It should be remembered that forced ligation of the common or internal carotid artery in case of injury in 30% of cases leads to death due to severe disorders of cerebral circulation. Equally unfavorable is the prognosis for the development of a bifurcation thrombus, which sometimes develops with an incorrect choice of the level of ligation of the external carotid artery. To avoid this complication, the ligature on the external carotid artery must be applied above the origin of its first branch - a. thyreoidea superior.

Topography of the cervical part of the thoracic lymphatic duct

Injuries to the cervical part of the thoracic duct are observed during sympathectomy, strumectomy, removal of supraclavicular lymph nodes, endarterectomy from the common carotid artery. The main clinical manifestation of a violation of the integrity of the thoracic duct is chylorrhea - the outflow of lymph. Measures to eliminate chylorrhea are tamponade of the wound or ligation of the ends of the damaged duct.

In recent years, the operation of imposing a lymphovenous anastomosis between the end of the damaged thoracic duct and the internal jugular or vertebral vein has been used. Access to the thoracic duct and its isolation for repair of damage or performing catheterization and drainage in typical cases is carried out along the medial edge of the sternocleidomastoid muscle. It should be emphasized that the cervical part of the thoracic duct is difficult to access for direct examination.

Tracheostomy is the operation of opening the trachea with the subsequent introduction of a cannula into its lumen in order to provide immediate air access to the lungs in case of obstruction of the overlying sections of the respiratory tract. The first operation was carried out by the Italian Antonio Brassavola (1500–1570). Classic indications for tracheostomy: foreign bodies of the respiratory tract (if it is impossible to remove them with direct laryngoscopy and tracheobronchoscopy); impaired airway patency in wounds and closed injuries of the larynx and trachea; acute stenosis of the larynx in infectious diseases (diphtheria, influenza, whooping cough, measles, typhus or relapsing fever, erysipelas); stenosis of the larynx with specific infectious granulomas (tuberculosis, syphilis, scleroma, etc.); acute stenosis of the larynx in nonspecific inflammatory diseases (abscessing laryngitis, laryngeal tonsillitis, false croup); stenosis of the larynx caused by malignant and benign tumors (rarely); compression of the tracheal rings from the outside by struma, aneurysm, inflammatory infiltrates of the neck; stenoses after chemical burns of the mucous membrane of the trachea with acetic essence, caustic soda, sulfuric or nitric acid vapors, etc.; allergic stenosis (acute allergic edema); the need to connect artificial respiration apparatus, artificial lung ventilation, controlled breathing in case of severe traumatic brain injury; during operations on the heart, lungs and abdominal organs; in case of poisoning with barbiturates; with burn disease and many other less common conditions. Tracheostomy requires both general surgical instruments (scalpels, tweezers, hooks, hemostatic forceps, etc.) and a special set of instruments. The set of the latter usually includes: tracheostomy cannulas (Luer or Koenig), a sharp single-tooth tracheostomy hook of Chessignac, a blunt hook for pushing back the isthmus of the thyroid gland; tracheo dilator for pushing the edges of the tracheal incision before inserting a cannula (Trousseau or Wulfson) into its lumen. Depending on the place of opening of the trachea and in relation to the isthmus of the thyroid gland, there are three types of tracheostomy: upper, middle and lower. With an upper tracheostomy, the second and third tracheal rings are cut above the isthmus of the thyroid gland. The intersection of the first ring, and, moreover, the cricoid cartilage, can lead to stenosis and deformation of the trachea or chondroperichondritis, followed by stenosis of the larynx. With a middle tracheostomy, the isthmus of the thyroid gland is dissected and the third and fourth tracheal rings are opened. With a lower tracheostomy, the fourth and fifth tracheal rings are opened below the isthmus of the thyroid gland. During the operation, the patient can be either in a horizontal position, lying on his back with a roller placed under the shoulder blades, or in a sitting position with his head slightly thrown back. The operator becomes to the right of the patient (with the upper and middle tracheostomy) or to the left (with the lower one). The patient's head is held by an assistant in such a way that the middle of the chin, the middle of the upper notch of the thyroid cartilage and the middle of the jugular notch of the sternum are located on the same line. The incision is made strictly along the midline of the neck. With an upper tracheostomy, the incision is made from the level of the middle of the thyroid cartilage down by 5-6 cm. The “white line” of the neck is cut along the probe and the long muscles located in front of the trachea are pulled apart. Immediately below the thyroid cartilage, the visceral sheet of the 4th fascia is dissected in the transverse direction, fixing the isthmus of the thyroid gland to the trachea. With a lower tracheostomy, the incision of the skin and subcutaneous tissue starts from the upper edge of the jugular notch of the sternum and is carried upwards by 5–6 cm. The 2nd fascia of the neck is dissected, the tissue of the suprasternal interaponeurotic space is bluntly stratified, if necessary, bandaged and crossed here arcus venosus juguli. The 3rd fascia is cut along the probe and the sternohyoid and sternothyroid muscles are moved apart. Below the isthmus, the 4th fascia is incised and the isthmus is displaced upward, exposing the 4th–5th tracheal rings. Before opening the trachea, to suppress the cough reflex, it is recommended to inject 1–1.5 ml of a 2% dicaine solution into its lumen with a syringe. The opening of the trachea can be done either by a longitudinal incision or a transverse one. According to special indications (for example, in patients who are on controlled breathing for a long time), a tracheostomy method is used with cutting out a flap according to Bjork or excising a section of the wall to form a “window”. During a longitudinal dissection of the trachea, the scalpel is held at an acute angle to the surface of the trachea (not vertically), with the belly up and 2 rings are crossed after tracheal puncture by moving from the isthmus of the thyroid gland and from the inside outward, as if “ripping” the wall. This technique allows avoiding injury to the posterior wall of the trachea, as well as dissecting the movable mucous membrane along the entire length of the incision. With a longitudinal dissection of the trachea, the integrity of the cartilage is inevitably violated, which in the future can lead to cicatricial deformity and the development of tracheal stenosis. Transverse dissection of the trachea between the rings is less traumatic.

Complications: bleeding from damaged cervical veins, carotid arteries or their branches, veins of the thyroid plexus, innominate artery, as well as when the isthmus of the thyroid gland is injured; incomplete dissection of the mucous membrane, which leads to its exfoliation with cannulas; “falling through” the scalpel and wounding the posterior wall of the trachea or esophagus; recurrent nerve damage. After opening the trachea, respiratory arrest (apnea) is possible due to reflex spasm of the bronchi.

Topographic anatomy and operative surgery of the thyroid gland

Surgeons began to develop operations on the thyroid gland from the end of the last century. Of the foreign surgeons, Kocher (1896) should be noted, who developed in detail the technique of operations on the thyroid gland. In Russia, the first operation was performed by N. I. Pirogov in 1849. The thyroid gland consists of two lateral lobes and an isthmus. The lateral lobes are adjacent to the lateral surfaces of the thyroid and cricoid cartilages and the trachea, reach the lower pole of 5–6 tracheal rings and do not reach the upper edge of the sternum by 2–3 cm. The isthmus lies in front of the trachea, at the level of its 4th rings. The upper edge of the isthmus sometimes comes into contact with the lower edge of the thyroid cartilage. The gland is closely connected with the underlying tissues by loose connective tissue and ligaments, especially with the larynx and the first tracheal rings. Due to this fixation, it follows the movements of the pharynx and trachea during swallowing. Palpation of the gland at the time of swallowing helps to detect even small enlargements and seals, especially in the lower parts of the gland. The posterior medial surfaces of the lateral lobes of the thyroid gland are adjacent to the esophageal-tracheal grooves, in which the recurrent nerves are located. In this zone, exfoliation of a thyroid tumor requires special care, since aphonia may develop if the recurrent nerves are damaged. The neurovascular bundles of the neck (common carotid artery, vagus nerve and internal jugular vein) are adjacent to the outer sections of the lateral lobes of the gland. In this case, the common carotid artery is so closely in contact with the gland that a longitudinal groove is formed on it. The lateral lobes touch the anterolateral wall of the esophagus. The blood supply to the gland is carried out by branches of the external carotid and subclavian arteries. Paired superior thyroid arteries, arising from the external carotid arteries, approach from the posterior surface to the upper poles of the lateral lobes and branch mainly in the anterior sections of the gland. Paired inferior thyroid arteries, arising from the subclavian arteries (truncus thyreocervicalis), approach the lower poles of the lateral lobes and supply mainly the posterior sections of the gland with branches. In 10–12% of cases, the inferior thyroid artery, which directly departs from the aorta and enters the lower isthmus of the gland, participates in the blood supply.

One of the most common thyroid surgeries is a strumectomy. The technique of the most frequently used operation was developed by O. V. Nikolaev (1964). It is called subtotal subcapsular resection of the thyroid gland. Surgical access is carried out by a horizontal arc-shaped incision 1-2 cm above the jugular notch of the sternum 8-12 cm long along one of the transverse skin folds ("collar" incision). When dissecting soft tissues, a thorough ligation of the vessels is performed. The resulting flaps, including the skin, subcutaneous tissue and superficial fascia, are peeled off in a blunt way and bred up and down. The sternohyoid muscles are transversely crossed. After the introduction of novocaine under the sternothyroid muscles and into the fascial sheath of the thyroid gland, the muscles are moved apart from the midline, and the parietal sheet of the 4th fascia of the neck is dissected. By displacing the edges of the dissected fascia in a blunt way, they provide an approach to the thyroid gland and begin to perform an operative technique. The allocation of the organ begins with the "dislocation" of the gland, usually from the right lobe, depending on the situation from the upper or lower poles. After the release of the right lobe, the isthmus of the thyroid gland is crossed along the probe (or under the control of a finger). As the isthmus is dissected, hemostatic clamps are applied sequentially. Less often, the isthmus is crossed between the clamps, followed by stitching its tissue and tightening the ligatures. This is followed by a "navicular" excision of the tissue of the right lobe of the gland, which is performed under the control of the finger. This moment requires a thorough stop of bleeding and the imposition of a large number of clamps. By controlling the movement of the scalpel with a finger under the gland, a narrow plate of gland tissue is left in the area that is considered a “dangerous” zone, since the recurrent nerve and parathyroid glands are adjacent to it behind. The remaining part of the gland (a plate of tissue of the right and left lobes a few millimeters thick) should be sufficient to prevent hypothyroidism. The medial and lateral edges of the left parenchyma of the gland are sutured to each other in the form of two valves. The bed of the removed gland and the remaining stump is covered by the sternothyroid muscles. Then the sternohyoid muscles crossed during access are sutured and sutures are applied to the skin.

2. Features of primary surgical treatment of neck wounds

Neck wounds have the following features: the wound channel, due to the large displacement of tissues, becomes tortuous and the outflow of wound contents is difficult; often observe simultaneous damage to large vessels and organs of the neck; wounds of the larynx, trachea and esophagus become infected not only from the outside, but also due to the contents; possible aspiration of blood into the respiratory tract, asphyxia. The wound channel is opened widely, the direction of the incision is chosen depending on the localization of the wound. In the medial part of the neck, transverse incisions are preferable, in the region of the sternocleidomastoid muscle - longitudinal incisions corresponding to the direction of its fibers. In the lateral part of the neck, transverse or oblique transverse incisions are made (along the clavicle or subclavian vessels and the brachial plexus). Soft tissues are excised sparingly, as contractures can form as a result of scarring. Extremely carefully excised tissues in the depth of the wound in view of the danger of damage to large vessels and nerves. If it is necessary to cross the veins, they are preliminarily bandaged to prevent air embolism. When performing manipulations in the outer triangle of the neck, it should be remembered that in adults the dome of the pleura protrudes 3 cm above the collarbones. All opened cellular spaces are carefully drained. Surgical treatment of wounds of the larynx and trachea consists in the economical excision of damaged tissues and the obligatory imposition of a tracheostomy.

The damaged pharynx and esophagus are sutured with a double-row suture with synthetic threads, after which not only the paraesophageal and peripharyngeal tissues are drained, but also the posterior mediastinum.