DISSECTION 1.

SUPERFICIAL AND DEEP NECK AND PAROTID REGION

The major goal of this dissection is to revisit the anatomy of the region of the parotid gland and the neck. In addition to your dissections, prosections will be available to examine some of the finer points of the anatomy in which you might be interested that would take considerable time to dissect on your own.

OBJECTIVES
1. Parotid Region. a. Describe in words the location of the parotid gland and its division into superficial and deep lobes. Identify the superficial and deep components on your dissection. b. Demonstrate on the cadaver a couple of the branches of the Facial nerve (VII) and discuss their relation to the parotid gland. Is there any functional relationship? c. Describe the autonomic (parasympathetic) and sensory innervation to the parotid gland and locate, verbally, the otic ganglion. 2. Neck. a. Identify the sternocleidomastoid and trapezius muscles and their motor innervation by the Spinal Accessory nerve (XII) and sensory innervation by branches of the cervical plexus. b. It can be difficult to do, but take a shot at identifying the fascias of the neck and the structures that they invest: cervical investing fascia, pretracheal or visceral fascia, prevertebral fascia, carotid sheaths. If your memory is good, you may recall probing the retropharyngeal space during your first anatomy experience. c. Identify the cutaneous branches of the cervical plexus that emerge from along the posterior margin of the sternocleidomastoid muscle: transverse cervical, greater auricular, lesser occipital, supraclavicular. d. Demonstrate on the cadaver and on a colleague the borders of the cervical triangles and their major subdivisions: Anterior cervical triangle muscular and carotid triangles. Posterior cervical triangle occipital and omoclavicular triangles. e. Identify the submandibular salivary gland and demonstrate its relationship to the mylohyoid muscle. Describe, in words, its parasympathetic innervation. (Netter, 4th ed., Plates 60, 61) f. Demonstrate the infra- and suprahyoid muscles. The motor innervation of the infrahyoid muscles is largely by the ansa cervicalis try to identify it. The suprahyoid muscles are largely innervated by branches of cranial nerves. (Netter, 4th ed., Plates 27-31)

g. Identify the three muscles arising from the styloid process and their innervation: stylohyoid, styloglossus, stylopharyngeus (Netter, 4th ed., Plate 68). (This is a subject near and dear to all gross anatomists.) h. As a part of your exploration of the neck, you should identify the following cranial nerves: IX (difficult), X, XI and XII. i. Demonstrate anterior and middle scalene muscles, phrenic nerve and roots of the brachial plexus. (Netter, 4th edition, Plate 30) The plexus will be considered in detail in the second dissection.

3. Thyroid, Parathyroid, Recurrent laryngeal nerve. a. Discuss development of thyroid gland and explain the basis for location of thyroglossal duct cysts. b. Discuss development of parathyroid glands. c. Locate the superior laryngeal nerves and the inferior (recurrent) laryngeal nerves, left and right and trace their origins from the vagus nerves. (Netter 4th ed., Plates 75, 76, 80, see also Plate 235 for an excellent behind the scenes look at the two nerves.) 4. Blood supply to structures in the neck. a. Identify branches of the external carotid artery: superior thyroid, ascending pharyngeal, lingual, facial, occipital (and maybe maxillary and superficial temporal if you go high in the neck/parotid region). (Netter, 4th ed., Plate 69) b. Identify branches of the subclavian artery in the neck: vertebral artery, thyrocervical trunk (variable). (Netter, 4th ed., Plates 75, 76) 5. Miscellaneous. a. Identify the superior cervical ganglion and the sympathetic trunk. (Netter. 4th ed, Plate 130) b. Identify the thoracic duct and its entrance into the veins of the neck (Netter, 4th ed., Plate 206)

6. Surgical procedures to consider, and important relationships. a. Parotidectomy - facial nerve. b. Thyroidectomy - recurrent laryngeal nerve, parathyroid glands, superior and inferior thyroid arteries, superior, middle and inferior thyroid veins. c. Thyroglossal duct cysts - hyoid bone, mylohyoid, geniohyoid and genioglossus muscles. d. Scalene node biopsy - phrenic nerve.

e. Carotid endarterectomy - bifurcation of common carotid artery. f. Zenker's diverticulectomy - retropharyngeal space, cricopharyngeus portion of inferior pharyngeal constrictor.

DISSECTION 1. INSTRUCTIONS FOR DISSECTING SUPERFICIAL AND DEEP NECK AND PAROTID REGION
I. Skinning of face and neck and dissection of the parotid gland. Carefully skin the anterior and lateral aspects of the neck and the portion of the face below the zygomatic arches. If this is accomplished successfully, you should see clearly several of the muscles of facial expression in the midface region, and the platysma muscle (Figure 1, below). Remove the fat over and at the borders of the parotid gland to show the gland in its entirety. The Facial nerve (VII) passes through the gland, as shown in the sketch below. ON THE RIGHT SIDE, locate branches of the nerve traveling to the facial muscles and then follow one of the branches back through the parotid gland where it joins the main trunk of the facial nerve deep to the posterior aspect of the gland. TRACE at least one branch of the nerve as far as possible toward the facial muscles that it supplies. ON THE LEFT SIDE, after identifying a main trunk, FOLLOW it through the gland by picking away the tissue with a probe or forceps and trace the nerve towards the stylomastoid foramen. IDENTIFY the stylomastoid foramen on one of the skulls in the laboratory, the site where the facial nerve emerges from its facial canal. NOTE: the parotid gland is very tough, so you may have to do some cutting in conjunction with the blunt dissection to trace branches of the nerve through the gland.

Figure 1.

II. Dissection of superficial neck, anterior and posterior cervical triangles. dissection should be done on both sides. 1)

This

BOTH SIDES of the neck should have the skin removed. REMOVE the platysma muscles by reflecting them carefully and cutting them from their attachment to the mandibles to expose the superficial aspect of the neck. Preserve the thin external jugular vein that crosses the sternocleidmastoid muscle. See Netter, Plate 31. Dissect the sensory branches of the cervical plexus (Netter, Plate 24 and Fig. 2, below). The cervical plexus consists of both sensory and motor nerves coming from cervical spinal nerves 1 4. The four sensory nerves emerge from behind the sternocleidomastoid muscle. BREAK the very tough cervical investing fascia over the sternocleidomastoid muscle with a probe, splitting the tissue parallel to the muscle fibers. This should expose the great auricular nerve that crosses the muscle, often in parallel with the external jugular vein, on its way toward the skin of the auricle. Under the same tough fascia and near the emergence of the great auricular nerve you may find two other slender cutaneous nerves the transverse cervical and the lesser occipital nerves. Find the Spinal Accessory nerve (XI) in the investing fascia as it crosses the posterior cervical triangle to reach the trapezius muscle (Fig. 2). In the cranial half of the posterior triangle (the space between the posterior edge of the sternocleidomastoid and the anterior edge of the trapezius) use a probe to break the tough fascia and trace the nerve to trapezius. The nerve provides motor innervation to sternocleidomastoid and trapezius and emerges from the cranial cavity through the jugular foramen. Sensory/proprioceptive innervation to the muscles is provided by branches from sensory components of the cervical plexus. Finally, clean the floor of the posterior triangle to show the supraclavicular branches of the cervical plexus, some of the very large nerves of the brachial plexus and the scalene muscles. See Netter, Plate 32.

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STRUCTURES RELATED TO THE POSTERIOR CERVICAL TRIANGLE: 1) Sternocleidomastoid 2) Trapezius 3) Lesser occipital nerve 4) Great auricular nerve 5) Transverse cervical nerve 6) Supraclavicular nerves 7) Spinal Accessory nerve

Figure 2.

III. Dissection of structures of the anterior aspect of the neck the anterior triangle. This should be done on both sides. (Netter, Plates 28 32, Plate 53) 1) First, cut the attachments of the sternocleidomastoid muscle from the sternum and clavicle and reflect the muscle towards the mastoid process. The investing fascias of the neck do make this a rather difficult task. Take care to identify the Spinal Accessory nerve (XI) as it enters the muscle and then crosses the posterior triangle (See Fig. 2). Locate the supra- and infrahyoid muscles (Fig. 3). The hyoid bone is a moveable bone in the neck. The suprahyoid muscles elevate this bone at the beginning of swallowing and the infrahyoid muscles depress the bone to its original position as swallowing is terminated. Branches of the cervical plexus the ansa cervicalis innervate the infrahyoid muscles (exception is thyrohyoid) while branches of cranial nerves innervate the suprahyoid muscles (an exception is geniohyoid). Identify the infrahyoid muscles: sternohyoid, sternothyroid, omohyoid, and thyrohyoid IDENTIFY the suprahyoid muscles posterior and anterior digastric bellies, mylohyoid and stylohyoid. Cut the attachment of the anterior belly of digastricus from the mandible. Retract the muscle to the hyoid bone and cut the fibrous loop that binds it to this bone. This will give you an excellent view of the mylohyoid muscle. The muscle called geniohyoid is positioned deep to mylohyoid and can be seen the dividing the mylohyoid in the midline and reflecting the cut ends.

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SUPRAHYOID MUSCLES 1) Posterior, anterior bellies of digastric 2) Stylohyoid 3) Mylohyoid 5) Fibrous loop of digastric muscle

Figure 3.

III. Dissection of structures of the anterior aspect of the neck the anterior triangle. This should be done on both sides. (Netter, Plates 28 32) 3) Locate the ansa cervicalis (Netter, Plate 32; Fig. 4, below). The ansa cervicalis consists of motor branches from the cervical plexus innervating the infrahyoid muscles. Probing in the fascia of the very tough carotid sheath, containing the internal jugular vein and common carotid artery, will usually reveal the nerve loop. Once the loop is identified, follow its superior limb to its approximation with the Hypoglossal nerve (XII) high in the neck, then follow the inferior limb of the ansa to its source from the cervical nerves.

Figure 4.
RELATIONSHIP OF THE ANSA CERVICALIS TO THE CAROTID SHEATH AND THE HYPOGLOSSAL NERVE. 6) Superior loop of ansa cervicalis traveling adjacent to the Hypoglossal nerve 7) Inferior loop of ansa cervicalis 10) Hypoglossal nerve (XII)

IV. Dissection of structures of the deep neck. This is largely in the region of the posterior triangle. (Netter, Plates 69 74) The numbers in this sequence correlate with the numbers in the illustrations in Figures 5 and 6 on the following pages. YOU MAY WISH TO DISSECT STRUCTURES OF THE DEEP NECK ON THE LEFT SIDE ONLY. 1) 2) With a saw, cut the mandibular symphysis to mobilize the mandibles. It is reasonable to remove a portion of the body and ramus for better exposure. With a saw, divide both clavicles as far laterally as possible and cut both first ribs as shown in Fig. 5. Do not cut the ribs as far laterally as the clavicles to avoid cutting the nerves of the brachial plexus. Then, cut the attachments of the sternohyoid and sternothyroid muscles to the sternum. Use your fingers to separate bluntly the soft tissues from the deep surface of the sternum and clavicles and remove the thoracic bony brim intact to expose the structures of the lower part of the neck and the upper part of the thorax. Clean the surface of the left internal jugular vein as close to the skull as possible and then inferiorly to the subclavian vein. Remove the fat carefully with a forceps behind the junction of the left internal jugular vein and subclavian veins to find the terminal part of the thoracic duct and its entrance into the veins at that junction. Note that it curves behind the left carotid sheath on its path to the veins. The duct may be filled with clotted blood so that it resembles a vein here. Ordinarily, the duct forms a distinct loop before joining the veins (Netter, Plate 206). Divide and reflect the internal jugular vein or remove the vein to make dissection of the deeper areas of the neck easier. Pull aside the anterior and posterior bellies of the digastric muscle. With a probe, find the long styloid process in the tissues anterior and inferior to the auricle, or find the process by identifying the stylohyoid muscle and following it posterior and superiorly to the styloid process. Also, identify the process on a skull. Identify the three muscles attaching to the styloid process: stylohyoid (outermost), styloglossus (middle) and stylopharyngeus (innermost). (Netter, Plates 53, 59, 69). They are innervated, respectively, by branches of the Facial nerve, Hypoglossal nerve, and Glossopharyngeal nerve. If you are interested in seeing the Glossopharyngeal nerve (IX) that innervates the stylopharyngeus muscle, you can find it by exposing stylopharyngeus and pulling it superiorly with a forceps. The nerve lies deep to the muscle before running anteriorly across its external surface near the muscles attachment into the pharynx. Look closely at Netter, Plate 69, to see the nerve. Trace the branches of the external carotid artery: superior thyroid, ascending pharyngeal, lingual, facial, occipital, posterior auricular, maxillary and superficial temporal (Netter, Plates 32-34, 69). The ascending pharyngeal artery is a very small branch off the medial side of the external carotid artery or is sometimes a branch of the facial artery. Note that the Hypoglossal nerve (XII) is very closely related to the origin of the occipital artery. The only certain way to identify the arteries is to trace each to its namesake structure.

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Figure 5.

IV. Dissection of structures of the deep neck. This is largely in the region of the posterior triangle. (Netter, Plates 69 74) The numbers is this sequence correlate with the numbers in the illustrations in Figures 5 and 6. 8) Expose the left subclavian artery as it arises from the aortic arch and locate the three branches coming off medial to the anterior scalene muscle: thyrocervical trunk, vertebral artery, internal thoracic artery (Netter, Plates 32 and 33, 74-76). There is also a small branch called the costocervical trunk that we will ignore. After the subclavian artery crosses the first rib, it becomes the axillary artery. Finish removing fat from the inferior cervical region so that the great vessels of the heart can be seen, and the vessels of the aortic arch: right brachiocephalic, left common carotid, left subclavian. 9) Find the Vagus nerve (X) accompanying the common carotid artery. Trace the nerve inferiorly. ON BOTH SIDES OF THE NECK YOU SHOULD IDENTIFY THE RECURRENT LARYNGEAL NERVES. On the left side, the nerve recurs around the ligamentum arteriosum and aortic arch. On the right side the nerve recurs around the right subclavian artery. Follow at least one of the recurrent nerves to the larynx, where it is called the inferior laryngeal nerve and note its relationship to the inferior thyroid artery (Netter, Plates 74 76). Find the internal branch of the superior laryngeal nerve as it penetrates the lateral aspect of the thyrohyoid membrane, a dense connective tissue membrane that attaches the hyoid bone to the thyroid cartilage. You may also wish to trace the external branch of the superior laryngeal nerve (Netter, Plates 75 and 76). This nerve travels with the superior thyroid artery until it enters the cricothyroid muscle (Netter, Plate 80). Now, follow the superior laryngeal nerves to where they branch from the Vagus nerve. 10) Find the large Hypoglossal nerve (XII) as it crosses the neck near the origin of the occipital artery and trace the nerve into the tongue. Often the Hypoglossal nerve is located under the stylohyoid muscle just before the muscle attaches to the hyoid bone (Netter, Plate 71). High in the neck near the base of the skull, displace the internal carotid artery and Vagus nerve with your fingers. Clear away the fascia behind the upper portion of the internal carotid artery to find a large swelling lying against the vertebrae. This swelling is the superior cervical ganglion of the sympathetic trunk (Netter, Plate 131). Follow the thin trunk inferiorly to its continuation as the thoracic sympathetic trunk. You may wish to trace the sympathetic trunk inferiorly to identify other ganglia, such as the stellate ganglion which is frequently a combination of the inferior cervical and first thoracic ganglia. This ganglion supplies some of the postsynaptic sympathetic fibers to the brachial plexus. Expose the thyroid gland and its blood supply superior and inferior thyroid arteries. Inspect the isthmus region for a pyramidal lobe. If you have led a good life, you may identify the parathyroid glands on the posterior aspect of the thyroid (Netter, Plates 74 and 75).

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Figure 6.