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Anterior triangles of neck
- 1. ANTERIOR TRIANGLES OF NECK Presentedby Dr.Kathirvel.G MDS (OMFS)
- 2. Contents: • Triangles ofthe neck Anterior triangle of Neck • Submental triangle • Submandibular triangle • Carotid triangle • Muscular triangle • Journal Club discussion
- 3. TRIANGLES OF NECK: Anterolaterally,neck is quadrilateral in shape Boundaries: Anteriorly : Midline of neck Posteriorly : Anterior border of trapezius Superiorly : Inferior border of mandible Inferiorly : Clavicle
- 4. Sternocleidomastoid muscle: Passes obliquelyupwards and backwards Origin : Clavicle and sternum Insertion : Mastoid process and occipital bone Sternocleidomastoid muscle divides the quadrilateral area into two triangle • Anterior triangle • Posterior triangle
- 5. ANTERIOR TRIANGLES OFNECK: Boundaries: • Anteriorly : The midline of the neck • Posteriorly : The anterior border of the sternocleidomastoid muscle • Superiorly/ Base : The inferior border of the mandible B.D.Chaurasia – Human anatomy – Fifth edition – Volume 3
- 6. Divisions: 3 paired and1 unpaired. Unpaired triangle: • Submental triangle Paired triangles: • Submandibular triangle • Carotid triangle • Muscular triangle Kikuta Et al; Triangles of the neck: a review with clinical/surgical applications; Anatomy and Cell biology; 2019
- 7. SUBMENTAL TRIANGLE: Boundaries: Anteriorly :Midline of neck Posteriorly : Anterior belly of digastric Base / Inferiorly : Body of the hyoid bone Floor : Mylohyoid muscle B.D.Chaurasia – Human anatomy – Fifth edition – Volume 3
- 8. Contents: • Submental lymphnodes • Small veins anastomose to form the anterior jugular vein. • As the anterior belly of the digastric muscle can present with variable anatomy or even be absent, the submental triangle can be distorted or absent. Kikuta Et al; Triangles of the neck: a review with clinical/surgical applications; Anatomy and Cell biology; 2019
- 9. • Two accessorybellies originated anteriorly to the intermediate tendon of the digastric muscles • Appeared fused along the midline and inserted on the medial surface of mandible
- 10. Applied aspects: • Anyodontogenic infection in anterior teeth, usually appear as an abscess or fistula on the skin in the chin area. • Occasionally, they can spread out into the submental space and form an abscess. • The risk of the incision is low because structures within the triangle are sparse and include no arteries. Kikuta Et al; Triangles of the neck: a review with clinical/surgical applications; Anatomy and Cell biology; 2019
- 11. Submandibular triangle: Area betweenbody of the mandible and hyoid bone Boundaries: Anteriorly : Anterior belly of digastric muscle Posteriorly : Posterior belly of digastric muscle Superiorly : Inferior border of the mandible Floor : Mylohyoid muscle B.D.Chaurasia – Human anatomy – Fifth edition – Volume 3
- 12. Contents: Nerves: • Marginal mandibularbranch of the facial nerve • Nerve to the mylohyoid • Hypoglossal nerve Arteries and veins: The facial and lingual arteries and veins Others: • Submandibular gland • Lower pole of the parotid gland • Lymph nodes. Kikuta Et al; Triangles of the neck: a review with clinical/surgical applications; Anatomy and Cell biology; 2019 Marginal mandibular nerve Mylohyoid nerve Hypoglossal nerve Facial artery and vein Submandibular gland Parotid gland
- 13. Layers: Superficial structure: • Platysma •Facial vein • Marginal mandibular branch of facial nerve After removal of superficial layer • Submandibular gland
- 14. Remaining structure • Facialartery • Lingual nerve • Lingual artery • Hypoglossal nerve
- 15. Applied aspects: The attachmentof the mylohyoid muscle onto the mandible is more inferiorly in the anterior region and more superiorly in the posterior region of the triangle. Infection from lower molar tooth could easily spread below the mylohyoid muscle into the submandibular space. Submandibular lymph nodes are clinically very important because of its wide range of drainage. Kikuta Et al; Triangles of the neck: a review with clinical/surgical applications; Anatomy and Cell biology; 2019
- 16. Applied aspects: The submandibularincision to access to this triangle should be inferior to the MMB. An incision two fingers-breadth below the inferior border of the mandible would provide safer access to the submandibular triangle than the 2 cm line below the inferior border of the mandible in order to avoid injury to the MMB. Davies et al; Evaluation of Clinically Relevant Landmarks of the Marginal Mandibular Branch of the Facial Nerve; Clinical anatomy; 2016
- 17. Two small trianglesare included : • Lesser’s triangle • Pirogov’s triangle Tubbs Et al; Three nearly forgotten anatomical triangles of the neck: triangles of Beclard, Lesser and Pirogoff and their potential applications in surgical dissection of the neck. Surgery Radiology anatomy; 2011
- 18. Lesser’s triangle: Named afterthe German surgeon Leon Lesser Also called the lingual triangle. Boundaries: Anteriorly : Anterior belly of digastric muscle Posteriorly : Posterior belly of the digastric muscle Superiorly : Hypoglossal nerve Floor : Hyoglossus muscle Lingual artery is found beneath it
- 19. Applied aspects: • Tubbset al. reported that Lesser's triangle was present in 30 out of 34 . • When it was absent, the hypoglossal nerve coursed inferior to the digastric muscle. • It is an ideal location for accessing the lingual artery. Tubbs et al; Three nearly forgotten anatomical triangles of the neck: triangles of Beclard, Lesser and Pirogoff and their potential applications in surgical dissection of the neck; Surgery radiology anatomy; 2011
- 20. Pirogov’s triangle: Named afterRussian surgeon Nikolai I. Pirogov This triangle is the posterior part of Lesser's triangle. Boundaries: Superiorly : Hypoglossal nerve Inferoposteriorly : Intermediate tendon of the digastric muscle Anteriorly : Posterior border of the mylohyoid muscle Van et al; Pirogoff’s Triangle revisited: an alternative site for microvascular anastomosis to the lingual artery; International journal of Oral and maxillofacial surgery; 2000
- 21. Applied aspects: • Tubbset al reported that Pirogov's triangle was found in 30/34 sides • When it was absent, the hypoglossal nerve coursed below the digastric muscle, as with Lesser's triangle. • This triangle constantly included the lingual artery deep to the hyoglossus muscle. Tubbs et al; Three nearly forgotten anatomical triangles of the neck: triangles of Beclard, Lesser and Pirogoff and their potential applications in surgical dissection of the neck; Surgery radiology anatomy; 2011
- 22. CAROTID TRIANGLE: Boundaries: Superiorly :Posterior belly of the digastric muscle Anteriorly : Superior belly of the omohyoid muscle Posteriorly : Anterior border of the SCM. Floor : Hyoglossus Thyrohyoid membrane Inferior and middle pharyngeal constrictor muscles. B.D.Chaurasia – Human anatomy – Fifth edition – Volume 3
- 23. Contents : Artery : Commoncarotid artery Internal External carotid artery (ICA) carotid artery (ECA) Superior thyroid Lingual Facial Occipital Ascending pharyngeal artery The anterior triangle of the neck; Harold Ellis, Vishy Mahadevan; Surgery 32:52; 2013
- 24. Variation in levelsof bifurcation of the common carotid artery, related to the cervical vertebrae SURGERY 32:52; 2013
- 25. Superior Thyroid Artery Origin: Common carotid artery - 19 cases (47.5%) External carotid artery - 12 cases (30%) Carotid bifurcation - 9 cases (22.5%) When it arise from the external carotid artery, the distance of origin from the bifurcation ranged from 2 to 10.5 mm. The distance of origin from the common carotid artery to the bifurcation ranged from 2 to 10.7 mm.
- 26. Lingual Artery The distanceof origin from the bifurcation ranged from 5 to 40 mm. In 8 cases the lingual artery shared a common trunk with the facial artery. Facial Artery The distance of origin from the carotid bifurcation ranged from 8 to 50 mm.
- 27. Veins: • Superior thyroid •Lingual • Facial • Ascending pharyngeal • Occipital Nerve: • Hypoglossal nerve • External and internal branches of the superior laryngeal nerve The anterior triangle of the neck; Harold Ellis, Vishy Mahadevan; Surgery 32:52; 2013
- 28. Carotid body: • Smallcluster of chemoreceptors near the bifurcation of common carotid artery • Detects changes in composition of blood passing through it, mainly Po2 • It is also sensitive to changes in Ph and temperature
- 29. Carotid sinus • Localizeddilation at the origin of internal carotid artery • Contains numerous Baroreceptors for maintaining blood pressure • It is innervated by sinus nerve of hering, which is a branch of glossopharyngeal nerve
- 30. Beclards triangle: Named afterthe French anatomist Pierre A. Beclard Boundaries: Superiorly : Posterior belly of the digastric muscle Floor : Posterior border of the hyoglossus muscle Inferiorly : Greater horn of the hyoid bone
- 31. Applied aspects: • Tubbset al examined Beclard's triangle and found it in 28/34 sides (84%) • With absent, the reasons were that the posterior belly of the digastric muscle did not attach to the hyoid bone, or directly located just above the greater horn of the hyoid bone. • Beclard's triangle constantly included both the lingual artery and hypoglossal nerve. • Convenient landmark for identifying both anatomical structures. Tubbs et al; Three nearly forgotten anatomical triangles of the neck: triangles of Beclard, Lesser and Pirogoff and their potential applications in surgical dissection of the neck; Surgery radiology anatomy; 2011
- 32. Farabeuf's Triangle Named forthe French surgeon Louis- Hubert Farabeuf Boundaries: Posteriorly : Internal Jugular Vein Anteroinferiorly : Common facial vein Anterosuperiorly : Hypoglossal nerve Kikuta Et al; Triangles of the neck: a review with clinical/surgical applications; Anatomy and Cell biology; 2019
- 33. Applied aspects: • Tubbset al. reported that Farabeuf's triangle was present in 75% (15/20 sides). • This triangle was constantly located within the carotid triangle and included at least one of the branches of the common carotid artery on 14 out of 15 sides. • Campbell et al., also mentioned that “this triangle is a helpful landmark in extensive dissections of the neck, especially in locating the IJV, the safety of which is best conserved by promptly exposing it.” Kikuta Et al; Triangles of the neck: a review with clinical/surgical applications; Anatomy and Cell biology; 2019
- 34. MUSCULAR TRIANGLE: Boundaries: Anteriorly :Midline of the neck Superiorly: Hyoid bone Inferiorly : Sternum Inferoposteriorly : Anterior margin of the Sternoclediomastoid Posterosuperiorly :Superior belly of the omohyoid muscle Kikuta Et al; Triangles of the neck: a review with clinical/surgical applications; Anatomy and Cell biology; 2019
- 35. Contents: Muscles - Sternohyoid Sternothyroid Omohyoid Thyrohyoid Artery- Superior thyroid artery Veins - Anterior jugular Inferior thyroid Nerve - Ansa cervicalis Kikuta Et al; Triangles of the neck: a review with clinical/surgical applications; Anatomy and Cell biology; 2019
- 36. Contents: Lymph nodes -Anterior cervical Infrahyoid Prelaryngeal Thyroid Pretracheal Paratracheal Other - Esophagus Trachea Thyroid gland Lower part of the larynx Kikuta Et al; Triangles of the neck: a review with clinical/surgical applications; Anatomy and Cell biology; 2019
- 37. Applied aspects: • Tracheostomyand thyroidectomy are invasive surgeries that access this triangle. • Skin incision should be made parallel to Langer’s line to avoid scar • During thyroidectomy, Injury of the superior thyroid artery can result in bleeding during surgery. Kikuta Et al; Triangles of the neck: a review with clinical/surgical applications; Anatomy and Cell biology; 2019
- 38.