Chapter 22: Neck

INTRODUCTION

One of the first reported cases of cervical trauma was in Homer’s Iliad when Achilles delivered a fatal lance blow to Hector’s neck, “where the clavicle marks the boundary between the neck and thorax.” This was portrayed by Peter Paul Rubens in about 1631 and hangs in the Museum Boymans-van Beuningen in Rotterdam, the Netherlands.¹ Treatment was first described by Ambrose Pare in the mid-16th century when he ligated the right carotid artery and jugular vein of a soldier ² who had suffered a bayonet wound. The patient survived, but was aphasic and developed a dense, left-sided hemiplegia.³ The first successful treatment of a major cervical vascular injury did not occur until 1803 when Fleming aboard the HMS Tonnant ligated the common carotid artery of a sailor after a suicide attempt while at sea. The sailor made a prolonged, but complete recovery.^4,5 A similar case was reported by Eves of Cheltenham, England, in 1849.⁶

ANATOMY

Knowledge of the surface landmarks of the neck is important for optimal evaluation and management of cervical injuries.⁷ The defining borders of the neck encompass the area between the lower margin of the mandible and the superior nuchal line of the occipital bone and the suprasternal notch and the upper borders of the clavicles.

The first palpable structure from the upper to lower border of the neck is the symphysis menti, which is where the two halves of the body of the mandible unite in the midline. The submental triangle, located between the symphysis menti and the body of the hyoid bone, is bounded anteriorly by the midline of the neck. Laterally, it is bounded by the anterior belly of the digastric muscle and the mylohyoid muscle forms the floor. The body of the hyoid bone lies opposite the third cervical vertebra. The area between the hyoid bone and the thyroid cartilage is the thyrohyoid membrane, while the notched upper border of the thyroid cartilage is at the level of the fourth cervical vertebra. The cricothyroid ligament or membrane occupies the space between the thyroid cartilage and the cricoid cartilage, which lies at the level of the sixth cervical vertebra and the junction of the pharynx with the esophagus. The interval between the cricoid cartilage and the first tracheal ring is filled by the cricotracheal ligament. Moving inferiorly, the isthmus of the thyroid gland is at the level of the second, third, and fourth tracheal rings. The suprasternal notch can be palpated between the clavicular heads and lies opposite the lower border of the body of the second thoracic vertebra. The sternocleidomastoid muscles, which divide the sides of the neck into anterior and posterior triangles, can be palpated from sternum and clavicle to the mastoid process. The borders of the posterior triangle are the body of the mandible, the sternocleidomastoid muscle anteriorly, and the border of the trapezius muscle posteriorly ...