NECK VIVAS

Sample viva, 2006-2Photo – side of neck (?)What structures can you identify in this picture?

Can you describe the branches of the internal and external carotid?

Although a lot of structures have been removed, can you discuss and demonstrate the relations of the int & ext carotid?

2011-1, (2010-2), 2008-2,

Bifurcation of Common Carotid- At superior border of thyroid cartilage (~C4)

Internal Carotid- No branches in the neck- Starts lateral -> posterior -> medial- Deep to the ECA to the side of pharynx- Enters cranium via carotid canal in petrous

part of temporal bone

External Carotid (+ 2010-2, 2008-2, 2004-2- 6 branches + 2 terminal- 3 anterior, 2 posterior, 1 medialS Superior thyroid AnteriorA Ascending pharyngeal MedialL Lingual AnteriorF Facial AnteriorO Occipital PosteriorP Posterior auricular PosteriorM Maxillary TerminalS Superficial temporal Terminal

Within carotid sheath:- At C4 the IJV is anterior -> higher = lateral- Vagus nerve inbetween (lateral -> deep)

Posterior is sympathetic trunk, pharyngeal vessels, superior laryngeal branches of vagus

Medial is ascending pharyngeal artery

Anterior is lingual and facial vessels hypoglossal n., SCM and post belly of diagastric.

External is separated from internal by:- Deep part of parotid- Stylo pharyngeus m.- Styloglossus m.- Glossopharyngeal n.- Pharyngeal branch of vagus n.

Lateral neck (+/- face) (pg 43)

Identify the major regions or triangles of the neckD: Anterior triangle (aka anterior cervical region) 2010-2, 2009-1 (discussion), 2007-1Bounded by midline, anterior border of SCM, inferior border of the mandible

C: Posterior triangle (aka lateral cervical region) Bounded by posteior border of SCM, anterior border of trapezius, middle 1/3 clavicle

Identify the carotid triangle and its boundaries 2011-1 Superior belly of omohyoid, posterior belly of digastric, anterior border of SCM

Identify the structures within the carotid triangle- Common carotid (10) and branches: ICA (24), ECA (- Branches of ECA: superior thyroid (52), lingual (28), facial (15), ascending pharyngeal medially- Internal jugular and tributaries (removed)- Nerves: Vagus, Hypoglossal (20), Superior root ansa cervicalis (24), spinal accessory, cervical

plexus- Thyroid gland, larynx and pharynx (22 = inferior constrictor)- Deep cervical lymph nodes

Name some structures in the anterior triangle 2010-2, 2005-1 - As above and:- Submandibular (digastric triangle): Submandibular gland almost fills triangle (46), submandibular

lymph nodes (20), hypoglossal nerve, mylohyoid nerve, parts of facial artery and vein- Submental triangle: submental lymph nodes and small veins unite to anterior jugular vein (3)- Muscular (omotracheal) triangle: Sternothyroid (44), sternohyoid (43), thyroid (59) and parathyroid

Describe the surface markings of the carotid sheath in the neck 2009-1 Carotid sheath runs along a line joining the sternoclavicular joint to a point midway between the mastoid process and the angle of the mandible.

What are the contents of the carotid sheathCommon carotid -> internal carotid artery, internal jugular vein, vagus nerve, some deep cervical lymph nodes, carotid sinus nerve, sympathetic nerve fibers

Describe the location of the thyroid gland in the neck- Located anteriorly in the neck at level of C5-T1- Lies deep to sternothyroid and sternohyoid muscles- Right and left lobes sit anterolateral to the larynx and trachea- A thin isthmus unites the two lobes across the trachea (usually at 2nd and 3rd tracheal rings)

2007-1Photo: Neck (pg 44)In this picture the sternomastoid has been removed. Identify the major blood vessels

Common carotid (7), external carotid (9), facial artery (11), suprascapular artery (37)Internal jugular (17), anterior jugular (4), retromandibular vein (28), facial vein (12)

What other structures can you identify in the picture?Submandibular gland (33), parotid / facial nerve (25), masseter (22), superior (bifid) omohyoid (34), digastric (3), mandible (21), hyoid (15), oblique line of thyroid (24), mylohyoid (23), sternohyoid (31), sternothyroid (32), SCM (30), scalenus anterior (29), thyroid gland (40), root of BP (5), Ansa cervicalis (inf 1, sup 2)

How does the internal jugular vein relate to the carotid artery? 2005-2 - Emerges from jugular bulb, initially behind ICA and lying on transverse process of atlas- Passes down to be lateral to ICA within carotid sheath, with the vagus nerve between- The terminal part lies superficial and lateral (deep to the junction of the heads of

sternocleidomastoid and joins the subclavian to form the brachiocephalic vein behind the medial end of the clavicle)

Please describe the surface marking of the internal jugular vein.From the earlobe (or mastoid) to the sternoclavicular joint (or medial part of clavicle).

2007-2, 2007-1X-ray: lateral C-spine

2010-1, 2008-2, 2008-1, 2004-2Model: larynx

What are the components of the soft tissue shadow located anterior to the upper cervical vertebrae 2007-2 1. Anterior longitudinal ligament2. Longus colli muscle3. Prevertebral fascia4. Retropharyngeal space5. Alar fascia6. Buccopharyngeal fascia7. Pharyngeal muscle

Identify the structures shown in this xray1. Nasopharynx/posterior aspect of tongue /

soft palate2. Retropharengeal soft tissue3. Trachea/oesophagus4. Epiglottis5. Vallecula6. Vestibular fold/vocal fold7. Bony: C1, C2, BOS, Mandible, Spinous

processes, Laminae, Disc spaces, Larynx, Hyoid, Trachea

8. Thyroid cartilage

Identify the structures that make up the larynx- From epiglottis to inferior border of cricoid (C6)- Cartilages (9):1. Thyroid: sup/inf horns/oblique line/laryngeal

prominence/laminae/thyroid notch.2. Cricoid: cricothyroid joint allows change in

length of vocal cords.3. Epiglottis4. Paired: Cunieform, Corniculate, Arytenoid - Membranes: Thyrohyoid and quadrangular- Ligaments: Cricotracheal, median cricothyroid,

median and lateral thyrohyoid, aryepiglottic and thyroepiglottic

- The lateral cricothyroid (ligament/membrane) and vocal ligament = the conus elasticus

Describe the nerve supply of the larynx

Name the muscles of the larynx 2008-2, 2008-1Extrinsic:

The main supply to the intrinsic muscles is from the inferior laryngeal nerve, a branch of the recurrent laryngeal form the vagus X. This supplies:- Thyro-arytenoid- Post crico-arytenoid- Lat crico-arytenoid- Trans/oblique arytenoids- Vocalis

The external branch of the superior laryngeal which is from the vagus directly supplies:- Cricothyroid

Intrinsic (muscles of vocalization): Tensor: Cricothyroid

Relaxor: Thyroarytenoid

Vocalis relaxes post while tensing anterior

Adductors: Transverse and oblique arytenoids

Abductors: Posterior and lateral cricoarytenoid

Suprahyoid:- Mylohyoid (V3)- Geniohyoid (C1 via XII)- Stylohyoid (VII)- Digastric (ant: V3, post: VII)

Infrahyoid: (C1-3, ansa cervicalis)- Sternohyoid- Omohyoid- Sternothyroid- Thyrohyoid

Styolpharyngeus (IX, odd one out)