POSTERIOR TRIANGLE OF NECK AND ITS APPLIED

Presented by Moderator

Snehal kharche Dr. Arati S. Neeli

ContentsBoundariesMusclesNervesVesselsLymphaticsApplied aspect

Boundaries

Roof

Floor

Subdivisions of posterior triangle of neck

ContentsMuscles: inferior belly of

omohyoid

Nerves Accessory nerve

Root, trunks of brachial plexus and their branches :• Nerves to rhomboideus(dorsal scapular n)• Nerves to serratus anterior(long thoracic n)• Nerves to subclavius• Suprascapular nerve

Cervical nerves• Greater occipital nerve • Great auriclular nerve• Lesser occipital nerve• Transverse cervical nerve of neck• Supraclavicular nerve

3rd and 4th cervical nerves supplying trapezius

ArteriesOccipital arteryThird part of subclavian artery & branches of

subclavian artery• Suprascapular• Transverse cervical

VeinsExternal jugular vein & its tributariesSubclavian vein is lower down and not in the

triangle

Lymph nodesSupraclavicular lymph nodes are present

on posterior border of sternocleidomastoidOccipital nodes

Torticollis

Spinal accessory nerve palsy

The brachial plexus and subclavian artery may be compressed in the neck by

rudimentary cervical rib tight fibrous bandtight scalenus anterior muscle

giving rise to◦ sensory symptoms◦ vascular symptoms

Cervical ribPressure in the cervical rib will give rise to

local pain as well as pain referred to hand and forearm particularly in the ulnar portion

Brachial plexus palsies Upper brachial plexus (erb’s) palsy

These infants cannot move the shoulder and keep their arm extended and turned inward, giving the appearance of the “porter's tip hand."

Lower brachial plexus (klumpke’s) palsy

External jugular vein It can be used for assessing jugular venous

pressure and for catheterization.

Subclavian arteryPalpation and compression of the subclavian

artery in patients with upper limb hemorrhage

Cervical rib and scalenous anticus syndromeDysphagia lusoria

Neck dissectionFirst conceptual approach- KocherCrile introduced RND & was followed by Martin

Staging of Neck Nodes NX:

Regional lymph nodes can not be assessed

N0:No regional lymph node metastasis

N1:Metastasis in a single ipsilateral lymph nodes, 3 cm or less

N2:N2a:

Metastasis in a single ipsilateral lymph nodes, > 3 cm < 6 cm

N2b: Metastasis in multiple ipsilateral lymph nodes, not

more than 6 cm

N2c: Metastasis in bilateral or contralateral nodes not

more than 6 cm in diameter N3:

Metastasis in lymph nodes more than 6 cm in in greatest diameter

Lymph node levelsLevel I:

Ia- Submental group

Ib- Submandibular group

Level II:around upper third of IJV &

adjacent to SANIIa- located anteriorly to SANIIb- located posteriorly to SAN

Level III:around middle third of IJV

Level IV:around lower third of IJV

Level V (posterior triangle group):Va- spinal accessory nodesVb- nodes around transverse cervical vessels & supraclavicular node

Level VI:pre & paratracheal, precricoid, perithyroidal & those around reccurent laryngeal nerves

ClassificationRadical neck Dissection:

Removing all lymphatic tissues in regions I - V and include removal of SAN, SCM and IJV

Modified radical neck dissection:Excision of all lymph nodes removed with RND with preservation of one or more non-lymphatic structures, SAN, SCM and/or IJV Subtype I: Preserve SAN Subtype II: Preserve SAN & IJV Subtype III: preserve SAN, IJV and SCM

Selective Neck dissection:Any type of cervical lymphadenectomy with preservation of one or more lymph node groupsFour subtype: Supraomohyoid neck dissection- I to III Posterolateral neck dissection- II to IV Lateral neck dissection- II to V Anterior neck dissection- VI

Extended neck dissection:Any previous dissection and including one or more additional lymph node groups and/or non-lymphatic tissues

Lateral neck swellingsLymph nodesCystic hygromaPharyngeal pouchSubclavian aneurysm

Cystic hygromaFailure of one of the lymphatics to join major

lymph sac of body Infancy and early childhoodSoft, cystic, fluctuant

Pharyngeal pouch

Subclavian anuerysm

References Clinical Anatomy for medical students – Richard

Snell, 5th Ed. Student’s Gray’s anatomy Head and neck anatomy- James L. Hiatt Grant’s Method of Anatomy, A Clinical problem

solving approach, 11th Ed. Head and neck surgery otolaryngology- Byron J.

Bailey Otolaryngology head and neck surgery- Cumming’s Cancer of face and mouth- McGregor Stell & Maran’s Head and Neck surgery, 4th Ed. B D Chaurasia’s Human anatomy, Volumes 1 & 3 A Concise textbook of surgery – S Das, 3rd Ed. P J Mehta’s Practical Medicine