W Robert Rout

Forward Head Posture Fix

Forward Head Posture Fix

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The cervical esophagus is situated deep in the neck, where it lies in the visceral space, the space located between the pretracheal and prevertebral fascial layers of the neck ( Fig. 18-1 ). Exposure of the esophagus in this area requires some knowledge of the anatomy of the neck. ANATOMY

The neck is the portion of the body that lies between the head and trunk. Its superior boundary is the line of the inferior margin of the body of the mandible continued from the angle of the jaw through the mastoid process from the anterior to the posterior midline on both sides. Its inferior border anteriorly is delineated by the suprasternal notch and the superior margin of the clavicle; posteriorly it is defined by a line drawn from the acromioclavicular joint to the spinous process of the seventh cervical vertebra. This spinous process is the most prominent of the cervical vertebrae and is easily recognized. Other recognizable surface landmarks of the neck are as follows:

1. The sternocleidomastoid muscles ( Fig. 18-2 ), one on each side, form a prominence that runs from the mastoid process obliquely downward and medially (anteriorly) across the lateral surface of the neck to the medial portion of the clavicle and its junction with the sternum at the episternal notch. Each sternocleidomastoid muscle divides its side of the neck into an anterior and a posterior triangle.

2. The thyroid cartilage (Adam's apple), more prominent in men than in women, is easily visible and palpable as it protrudes in the anterior midline (see Fig. 18-2 ). It moves up and down when a person swallows.

3. The hyoid bone lies about 2.5 cm above the thyroid cartilage and moves on swallowing. It cannot be seen, but when steadied with fingers placed on both sides, it can be palpated. The greater horn of the hyoid bone lies about midway between the mastoid process and the thyroid prominence.

4. The arch of the cricoid cartilage can be felt (but not seen) in the anterior midline and is just inferior to the thyroid cartilage. It moves up and down on swallowing. Immediately below it, the butterfly-shaped thyroid gland can be palpated (see Fig. 18-2 ). This gland cannot be seen as a surface landmark unless it is enlarged. The cricoid cartilage is at the level of the palpable anterior tuberosity (carotid tubercle of Chassaignac) of the sixth cervical vertebra. This tubercle can be identified by applying pressure at the anterior border of the sternocleidomastoid muscle at this level, which serves as a landmark in ligation of the common carotid artery. It also marks the level at which the pharynx merges into the cervical esophagus to form the beginning of that structure.

5. The anterior edge of the trapezius muscle can be palpated and sometimes is seen as a ridge that forms the posterior boundary of the posterior triangle of the neck ( Fig. 18-3 ).

Cervical Fascial Layers

Encasing the neck are two main fascial layers called the superficial and the deep cervical fascia.

The superficial cervical fascia, barely demonstrable as a separate layer, lies immediately beneath the skin around the entire circumference of the neck. It contains the superficial vessels, nerves (see Fig. 18-1 ), and adipose tissue. It is separated from the investing lamella of the deep cervical fascia by the platysma muscle extending over the anterolateral portion of the neck ( Fig. 18-4 ). The platysma muscle arises from the deep fascia of the pectoral region and from the clavicle to pass upward to the inferior border of the mandible, beyond which it blends with some of the muscle of the face. In closing incisions made in the neck, it is important to approximate the cut edges of the platysma, including the superficial fascia, to minimize the unsightliness of the subsequent scar.

The deep cervical fascia consists of three layers that invest and support the muscles, pharynx, trachea, esophagus, lymph glands, large vessels, and nerves (see Fig. 18-1 ). The superficial (investing) layer of the deep cervical fascia forms a complete envelope for all the cervical structures except the platysma and the superficial vessels and nerves. It is attached above to the inferior margin of the mandible; posterior to the angle of the jaw, it continues upward to enclose the parotid gland and attaches to the zygomatic arch, mastoid process, occipital protuberance, and superior medial line. It splits and reunites at appropriate points to ensheathe the trapezius and sternocleidomastoid muscles. These lamellae are fused again to form a single layer anterior to the sternocleidomastoid

Figure 18-1 A, Transverse section through the left half of the neck to show arrangement of the deep cervical fascia. B, Part of a transverse section through the lower part of the neck at the level of the seventh cervical vertebra to show the arrangement of the deep cervical fascia. (Specimen provided by Prof. R.E.M. Bowden.) (From Warwick, R., and Williams, P.L. [eds.]: Gray's Antomy, 35th Br. ed. Philadelphia, W.B. Saunders, 1973, with permission.)

Hals Faszien Anatomie

Figure 18-2 A, Muscles of the front of the neck. On the right side, the sternocleidomastoid has been removed. In this subject, the origin of the scalenus medius extended up to the transverse process of the atlas. B, The anterior and lateral vertebral muscles. On the right side, the scalenus anterior and the longus capitis have been removed. (From Warwick, R., and Williams, P.L. [eds.]: Gray's Anatomy, 35th Br. e Philadelphia, W.B. Saunders, 1973, with permission.)

Gray Anatomy Rectum

isi rib

Figure 18-3 Subdivision of the anterolateral portion of the neck into triangular areas. A, Quadrilateral field bounded by the trapezius muscle (behind), mandible and occipital bone (above), midline of the neck (front), and clavicle (below). B, Subdivision into two triangular areas by the obliquely coursing sternocleidomastoid muscle. C, Further subdivision of the posterior triangle into occipital and supraclavicular triangles by the omohyoid muscle; comparable subdivision of the anterior triangle into submental, digastric, carotid, and muscular triangles by the omohyoid and digastric muscles. D, The triangles of the right side of the neck. (D, Modiñed from Warwick, R., and Williams, P.L. [eds.J: Gray's Anatomy, 35th Br. ed. Philadelphia, W.B. Saunders, 1973, with permission.)

Figure 18-4 Platysma muscle and related muscles of facial expression. The platysma, like the corresponding muscles of the face and scalp, is situated in the superficial fascia. This layer of tissue has been dissected away to expose the platysma muscle, the related triangularis, and other facial muscles in the subcutaneous stratum.

Subcutaneous Facial

Figure 18-6 The veins of the right side of the head and neck. Parts of the right sternocleidomastoid and platysma have been excised to expose the trunk of the internal jugular vein. The external jugular vein is visible through the lower part of the platysma. (From Williams, P.L., and Warwick. R. [eds.]: Gray's Anatomy, 36th Br. ed. Philadelphia, W.B. Saunders, 1980, with permission.)

Platysma And Jugular Vein

Figure 18-8 A dissection to show the prevertebral region and the superior mediastinum. On the right side, the costal elements of the upper six cervical vertebrae have been removed to expose the cervical part of the vertebral artery. On the left, most of the deep relations of the common carotid artery and the internal jugular vein are exposed. (From Williams, P.L., and Warwick, R. [eds.]: Gray's Anatomy, 36th Br. ed. Philadelphia, W.B. Saunders, 1980, with permission.)

Figure 18-9 Arteries of the head and neck shown in relation to skeleton and body outline. (From Jones, T, and Shepard, W.C.: A Manual of Surgical Anatomy. Philadelphia, W.B. Saunders, 1945, p. 155, with permission.)
Left Corona Radiata

Figure 18-10 Dissection of the right side of the neck to show relations to the superior and inferior laryngeal nerves. (From Nordland, M; The larynx as related to the surgery of the thyroid based on an anatomical study, Surg. Gynecol Obstet, 51:449, 1930, by permission of Surgery, Gynecology and Obstetrics.)

Figure 18-10 Dissection of the right side of the neck to show relations to the superior and inferior laryngeal nerves. (From Nordland, M; The larynx as related to the surgery of the thyroid based on an anatomical study, Surg. Gynecol Obstet, 51:449, 1930, by permission of Surgery, Gynecology and Obstetrics.)

Glossopharyngeal Neve Left Side Picture
Figure 18-11 Dissection of the left side of the neck to show relations of the recurrent laryngeal nerve. (From Nordland, M; The larynx as related to the surgery of the thyroid based on an anatomical study, Surg. Gynecol Obstet., 51:449, 1930, by permission of Surgery, Gynecology and Obstetrics.)
Glossopharyngeal Neve Left Side Picture
Figure 18-12 The course and distribution of the glossopharyngeal, vagus, and accessory nerves. (From Williams, P.L., and Warwick, R. [eds.]: Gray's Anatomy, 36th Br. ed. Philadelphia, W.B. Saunders, 1980, with permission.)
Bowel Sheet

Figure 18-13 A dissection to show the general distribution of the right hypoglossal and lingual nerves and the position, constitution, and some of the cervical plexus of the right side. (From Williams, P.L., and Warwick, R. [eds.]: Gray's Anatomy, 36th Br. ed. Philadelphia, W.B. Saunders, 1980, with permission.)

Glossopharyngeal Neve Left Side Picture

Figure 18-15 A, Structures in the deep portion of the left neck; anterolateral view. The sternocleidomastoid and the infrahyoid muscles have been partially removed, together with the clavicle and the subclavius muscle; the carotid artery and jugular vein remain as proximal and distal segments. The following structures are exposed: branches of the common carotid artery and subclavian artery; the constituents of the cervical and brachial plexuses of nerves; the middle and anterior scalenus muscles; the vagus nerve and spinal accessory nerve; and the thyroid gland and its arteries of supply. In this specimen, the cervical rami contributory to the trunks of the brachial plexus passed through a cleft in the scalenus anterior muscle, not between the latter and the middle scalenus. B, The left subclavian artery and its branches.

Primary And Secondary Muscle Groups
Figure 18-16 Cross section of the neck at the level of the seventh cervical vertebra to show the cervical approaches to the esophagus, inferior thyroid artery, phrenic nerve, and sympathetic gangliated chain.
Cutaneous Branches Cervical Plexus
Figure 18-18 Relations of the posterior belly of the digastric, exposed by the removal of skin, fasciae, parotid gland, and cutaneous branches of the cervical plexus. (From Williams, P.L., and Warwick, R. [eds.]: Gray's Anatomy, 36th Br. ed. Philadelphia, W.B. Saunders, 1980, with permission.)

Superficial Lateral ligament Superficial temporal témpora- Middle layer Superficial layer temporal vein artery mandibular joint of mästetet of masse ter

Facial nerve

Styloid process

Accessory nerve

Transverse process of atlas

Digastric, postertor belly

Accessory nene

Retromandibular vein

Internal jugular tern

External jugular vein

Facial nerve

Styloid process

Accessory nerve

Transverse process of atlas

Digastric, postertor belly

Accessory nene

Retromandibular vein

Internal jugular tern

External jugular vein

Brostrom Gould Repair Technique

Maxillary vein

Maxillary artery

Parotid duct

Maxillary vein

Maxillary artery

Parotid duct

Buccinator

Facial vein

Stylohyoid

Occipital artery Facial artery Hyoglossus

Body of hyoid bone

Hypo- Common carotid Superior thyroid Lingual glossal nerve bifurcation artery artery

Figure 18-19 Left side of neck. (From Boileau Grant, J.C.: An Atlas of Anatomy, 5th ed. Baltimore, Williams & Wilkins, 1962, with permission.)

Stemo-thyroid

Deep cervical lymph nodes

Internal ju guiar y ein

Thoracic duct

Stcrno-hyoid-

Ant. ste mo-clavicular ligament-

Figure 18-19 Left side of neck. (From Boileau Grant, J.C.: An Atlas of Anatomy, 5th ed. Baltimore, Williams & Wilkins, 1962, with permission.)

Stemo-thyroid

Deep cervical lymph nodes

Internal ju guiar y ein

Thoracic duct

Ant. ste mo-clavicular ligament-

Transverse cervical artery or Transversa colli art.

Suprascapular artery (Trans, scapular artery)

Transverse cervical artery or Transversa colli art.

/Phrenic nerve ■i Prevertebral fascia

Suprascapular artery (Trans, scapular artery)

Subclavian vein

Subclavius

Ant Cervical LymphadenopathyAnt Cervical Lymphadenopathy

Figure 19-3 Posterior view of the thorax and contiguous portions of the neck and abdominal wall. The left half illustrates the superficial muscles. The right half illustrates the deeper muscles and topographic relations of the lung and diaphragm. (From Sweet, R.H.: Thoracic Surgery, 2nd ed. Philadelphia, W.B. Saunders, 1954, p. 71, with permission.)

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dOTji M

Figure 19-4 Anterior view of the thorax and contiguous portions of the base of the neck and the anterior abdominal wall. The left side of the torso illustrates the superficial layer of muscles and fascia. The right side of the torso illustrates the relations of the deep muscles of the neck and abdomen to the rib cage; the intercostal muscles; the diaphragm; the internal mammary vessels; the relations of the muscles, nerves, and vessels with the first rib; and the anterior relations of the lung. (From Sweet, R.H.: Thoracic Surgery, 2nd ed. Philadelphia, W.B. Saunders, 1954, with permission.)

Thoracotomy Diagram
Figure 19-5 Diagram of an intercostal space. (From Sweet, R.H.: Thoracic Surgery, 2nd ed. Philadelphia, W.B. Saunders, 1954, with permission.)
Posterior Intercostal Space Diagram
Figure 19-6 Vertical sections through the ribs and intercostal spaces. A, Posterior to axilla. B, Anterior to axilla. To show the differences in the location of the intercostal vessels and nerves and the importance of these relations in intercostal thoracotomy.
Intercostal Muscles Diagram

Figure 19-7 Oblique cross section showing the relations of the Intercostal arteries to the ribs and Intercostal spaces. Posterior to the axilla, the arteries are protected; anterior to the axilla, they are more exposed.

Intercostal Space DiagramIntercostal Space Cross Section
Figure 19-9 Trunk muscles. The left sternocleidomastoid, pectoralis major, external oblique, and a portion of the deltoid have been removed to show underlying muscles. (From Borland's Illustrated Medical Dictionary, 28 th ed. Philadelphia, W.B. Saunders, 1994, with permission.
Classification Mosquitoes

Figure 19-11 Standard thoracotomy incision. View of the incision after division of the latissimus dorsi muscle and partial division of the lower portion of the trapezius muscle; the rib is partially exposed. (From Sweet, R.H.: Thoracic Surgery, 2nd ed. Philadelphia, W.B. Saunders, 1954, with permission.)

Figure 19-13 A through E, Arterial supply of the mammary gland; variations in the source, and anastomotic pattern of the vessels.

Figure 19-12 Diagram showing the direction taken by the fibers of the external and Internal Intercostal muscles, which extend across the Intercostal spaces.

Figure 19-13 A through E, Arterial supply of the mammary gland; variations in the source, and anastomotic pattern of the vessels.

Mam Artery

Ramus mam man us (branch of axillary artery)

Branches (lateral thoracic 5 branch of axillary artery}

Ramus mam man us (branch ot thoracoacromial artery of the axillary artery)

Ramus mam man us (brancn ot lateral thoracic branch of the axillary artery)

Ramus mammanus (branch of axillary artery)iC

Figure 19-14 The serratus posterior muscles. (From Marshall-Lazier: An Introduction to Human Anatomy, with permission.)

íé A M. terrains posterior iupenpr

Fascia oxer deep mujtits vj bvk

Fascia oxer deep mujtits vj bvk

If, urraiui posterior inferior

Figure 19-15a A, The right scapula, dorsal aspect.

Biceps (shor t head) Coracoid process Qn(j cvracobrachialis

Levator scapulae

Spine Trapezius

Infraspinatus

Tipos Huesos Humanos

Acromion

Diltoid

Rhomboidevs

Glenoid cavity

Teres major

Triceps brachii (long head)

Groove for circumflex scapular artery

Rhomboidevs

Acromion

Diltoid

Levator scapulae

Glenoid cavity

Teres major

Spine Trapezius

Triceps brachii (long head)

Infraspinatus

Groove for circumflex scapular artery

Figure 19-15a A, The right scapula, dorsal aspect.

Biceps (shor t head) Coracoid process Qn(j cvracobrachialis

Conoid Omohyoid (infer Superior angle

A Inferior angle

Figure 19-15b B, The right scapula, anterior (costal) aspect. (From Williams, P.L., and Warwick, R. feds.]: Gray's Anatomy, 36th Br. ed. Philadelphia, W.B. Saunders, 1980, with permission.)

Figure 19-15b B, The right scapula, anterior (costal) aspect. (From Williams, P.L., and Warwick, R. feds.]: Gray's Anatomy, 36th Br. ed. Philadelphia, W.B. Saunders, 1980, with permission.)

Figure 19-16 Superficial muscles of the back of the neck and upper trunk. On the left, only the skin and superficial and deep faciae have been removed; on the right, the sternocleidomastoid, trapezius, latissimus dorsi, deltoid, and obliquus externus abdominis have been dissected away. (Modified from Warwick, R., and Williams, P.L.: Gray's Anatomy, 35th Br. ed. Philadelphia, W.B. Saunders, 1973, with permission.)

Laiistimits dor s i

Trapezius

Deltoid

Erector Spinae Skin

posterior inferior

Erector Spinae

Obliquus internus

Figure 19-17 Lungs and their relations to the pleurae and mediastinum.

Semispinals capitis Splenitis capitis Rhomboid em mimr

Rhomboidem major i capulae

Infraspinatus

Teres minor

Teres major

ánterur posterior inferior

Erector Spinae

Laiistimits dor s i

Trapezius

Deltoid

Obliquus internus

TftyrortJ gland ( low-lying )

Brachiocephalic {innominate) artery

Superior lot» right lung M'ddPe lobe, nght lung

Diaphragmatic pleura

Inîenor lobe, left lung

Diaphragm

Figure 19-18 Anatomic divisions of the mediastinum.

Figure 19-17 Lungs and their relations to the pleurae and mediastinum.

Internal jugular vein Common carotid

Brachial plexus

TftyrortJ gland ( low-lying )

of the pleura (cervical pleura)

Brachiocephalic {innominate) artery

Superior lot» right lung M'ddPe lobe, nght lung

Mediastinal infenor lobe, nght lung Pericardium

Diaphragmatic pleura

Subclavian artery

Axillary vein Thymus pleura

Superior lobe, lett Mediastinal pleura Pencardium Pericardia' cavity

Inîenor lobe, left lung

Diaphragm

Figure 19-18 Anatomic divisions of the mediastinum.

Innominate Artery And Brachial Plexus

Figure 19-20 Minor thoracotomy incisions for drainage of empyema and lung abscess. 1, Inverted ^-shaped axillary incision for drainage of abscesses in the upper lobe of the lung. 2, Vertical incision over two or more adjacent ribs for drainage of empyema or abscess in the apex of the lung. For the latter, the incision must be made between the medial border of the scapula and the spine. 3, Oblique incision in the direction of a rib used in cases of empyema or pulmonary abscess where localization is accurate. 4, Transverse incision used in transpleural drainage of subdiaphragmatic or liver abscesses.

Figure 19-20 Minor thoracotomy incisions for drainage of empyema and lung abscess. 1, Inverted ^-shaped axillary incision for drainage of abscesses in the upper lobe of the lung. 2, Vertical incision over two or more adjacent ribs for drainage of empyema or abscess in the apex of the lung. For the latter, the incision must be made between the medial border of the scapula and the spine. 3, Oblique incision in the direction of a rib used in cases of empyema or pulmonary abscess where localization is accurate. 4, Transverse incision used in transpleural drainage of subdiaphragmatic or liver abscesses.

Figure 19-21 Technique of rib resection. Correct placement of incisions in the periosteum to avoid necrosis of rib ends in empyema or abscess cases. (From Sweet, R.H.: Thoracic Surgery, 2nd ed. Philadelphia, W.B. Saunders, 1954, with permission.)

Periosteal incisions

Figure 19-22 Lateral thoracotomy position. Direction and location of standard thoracotomy incision over the seventh rib are shown by dashed line. Scapula and important muscles are shown in outline. Note the angulation of the table, with pillow beneath the patient to arch the side of the operation so as to widen the intercostal spaces. The head is lower than the pelvis.

Figure 19-23 Standard thoracotomy incision (rib resection technique). Muscles are completely divided. Three phases of the elevation of the periosteum are shown, using the Lewis elevator to strip the outer aspect of the rib and to free the edges and the Doyen elevator to strip the inner surface of the rib. Insets show the technique of transection of the neck of the rib posteriorly and the cartilage anteriorly. (From Sweet, R. H.: Thoracic Surgery, 2nd ed. Philadelphia, W.B. Saunders, 1954, with permission.)

Anterior

Pencil Drawing Images

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