Neck

NECK (collum), being an intermediate link between the head and trunk, includes a number of important organs and tissues vital for life. The upper boundary of the neck is formed by the edge of the lower jaw and a line extending from the temporomandibular joint to the mastoid process and then to the external occipital tubercle along the superior nuchal line. The lower boundary of the neck is formed by the superior edge of the manubrium sterni - its jugular notch, the clavicles, and then a line connecting the acromioclavicular joints with the spinous process of the seventh cervical vertebra. In the first weeks of human embryonic development, the neck does not exist as a formed anatomical structure. Its external shape is gradually constructed as the embryo develops. In an embryo of 8 mm, the cardiac region lies directly adjacent to the head and no outlines of the neck are yet present. With further development, the head begins to move away from the cardiac region and the neck begins to appear. In an embryo of 14 mm, the boundaries of the neck begin to be outlined. At this point, the upper and lower jaws, the auditory canal, the auricle, and the contours of the sternocleidomastoid muscle become visible. In an embryo of 15 mm, the boundaries of the neck are well expressed. The development of the neck stands in direct connection with the development of the branchial apparatus and individual elements and organs of the face and neck, such as the oral cavity, pharynx, larynx, thyroid gland, etc. The external

Figure 1. System of grooves on the face, neck, and occiput. Combination from a large number of cases. (According to Pinkus.)

Figure 2. Deep, non-erasable folds extending from behind and above from the occiput forward and downward onto the neck. (Pinkus according to Muller.)

appearance of the neck is not finally completed at the time of birth, but continues to change for many years after birth. The shape of the neck depends on the constitution, sex, age, and condition of individual organs of the neck under the influence of various pathological processes. In asthenics, the neck is long, the circumference is comparatively small, and the shape is cylindrical, with a cross-section showing a figure approaching a circle over almost its entire length. For the picnic type, the neck is short and thick. The athletic neck resembles a truncated cone. Significant fat deposition in the chin and occipital regions, such as double or triple chin, occipital fat rolls, sharply affects the outlines of the neck. In women and children, the contours of the neck are smoothed. - The skin of the neck repeats the relief of the cervical organs. In youth, due to its elasticity, it tightly fits all the protrusions and hollows of the neck. In older age or after significant weight loss, the skin loses its elasticity and forms a series of folds and grooves running arcuiformly across the surface of the neck (fig. 1-3). The skin of the neck in the ventral part is more elastic, tender, and movable than on the occiput. There is a large number of sebaceous glands on the skin of the occiput. The elastic fibers of the skin of the neck go in a certain direction, forming, as in other places on the body, the so-called Langer's lines. The direction of the grooves and Langer's lines has certain significance for making cosmetic incisions and obtaining less noticeable scars on the neck. The subcutaneous fat layer of the anterior part of the neck is loose and movable. In the occipital region, the subcutaneous tissue is dense and immobile. Here, connective tissue fibers pass from the skin to the fascia of the trapezius muscle, forming a network, in the cells of which the fat lobules are located. The subcutaneous fat layer of the neck is developed more or less uniformly, with the exception of the chin and occipital regions, where fat deposits usually accumulate in larger quantities, forming in obese people the so-called double or triple chin and fat rolls on the occiput. In the thickness of the subcutaneous tissue or rather between it and the skin of the anterior-lateral surface of the neck passes the broad subcutaneous muscle of the neck (m. subcutaneus colli, s. platysma). The bundles of the subcutaneous

Figure 3. Man, 50 years old, with rhomboidally intersecting folds of skin on the occiput. (Pinkus according to Muller.)

muscle of the

The muscles begin from the fascia of the pectoral and deltoid muscles, pass upward through the clavicle, covering the entire front-lateral part of the Neck, and leave a free triangular space in the middle above the sternum (fig. 4). In the chin area, both muscles converge. With their terminal fibers, they attach to the parotido-masseteric fascia (f. parotideo-masseterica), the edge of the lower jaw, and are interwoven with the fibers of the square muscle of the lower lip. - In the subcutaneous tissue of the Neck are located the superficial cervical veins and subcutaneous nerves. The superficial venous system of the Neck is very variable. It consists of the external and anterior jugular veins and the median vein (vv. jugulares ext. and ant. and v. mediana). The most constant is the external jugular vein. The others may either replace each other or be absent altogether. Sometimes the anterior facial vein (v. facialis ant.) also flows into the external jugular vein at the level of the upper edge of the thyroid cartilage. The anterior jugular veins and the median vein either flow into the external jugular vein or, passing through the suprasternal interfacial space, pierce the blind fascial sac (see below) and flow into the venous angle (angulus venosus)-the place where the internal jugular and subclavian veins merge. Due to the intimate connection of the subcutaneous veins with the fasciae of the Neck, especially at the place of confluence into the deep veins, they, like the deep veins of the Neck, when severed, do not collapse but gape, which in surgical operations threatens with air embolism. In the subcutaneous tissue branch off the cutaneous branches of the cervical nerve plexus. The latter pass through the superficial fascia of the Neck at the posterior edge of the sternocleidomastoid muscle. They include the following nerves. The lesser occipital nerve (n. occipitalis minor) goes from under the posterior edge of the sternocleidomastoid muscle upward and backward parallel to its edge to the mastoid region, where it gives off anterior and posterior branches for the skin of the occiput and mastoid region. The great auricular nerve (n. auricularis magnus) curves around the posterior edge of the sternocleidomastoid muscle and rises upward to the ear along its outer surface. It goes behind the external jugular vein and in the area of the ear also divides into 2 branches-anterior, parotid (for the skin of the parotid gland area), and posterior (for the skin behind the ear and the mastoid process). The branches of the auricular nerve penetrate into the parotid gland, where they anastomose with the branches of the facial nerve (Rouviere). The middle cutaneous nerve of the Neck (n. cutaneus colli medius) breaks up into a group of branches, which curve around the posterior edge of the sternocleidomastoid muscle, go across the Neck and spread over its lateral and anterior surfaces. They cross the external jugular vein, usually located below it; the upper branch anastomoses with the cervical branch of the facial nerve. The supraclavicular nerves (nn. supraclaviculares) from the 3rd loop emerge from under the posterior edge of the sternocleidomastoid muscle and immediately go downward to the skin of the clavicle and the acromial process of the scapula. The fasciae of the Neck are described differently, but still most authors tend to distinguish 3 fascial layers. The superficial fascia of the Neck (f. colli superficialis)-a connective tissue plate of varying density in different parts of the Neck and in different individuals. It is more pronounced and dense in muscular people and in places where it forms a sheath for the muscles. The superficial fascia covers the Neck from all sides. On the posterior part of the Neck it attaches to the nuchal ligament (lig. nuchae), the superior nuchal line, the bone of the scapula, passing further into the superficial fascia of the back. On the anterior surface of the Neck along the midline it tightly fuses with the middle fascia, participating in the formation of the so-called white line of the Neck. Intimately fusing with the hyoid bone, it thus forms a natural boundary between the so-called supra- and infra-hyoid areas (on the face it fuses with the edge of the lower jaw and passes into the parotido-masseteric fascia). At the angle of the lower jaw, the fascia forms a significant thickening (pars angularis), which fixes the sternocleidomastoid muscle here. Below, the superficial fascia attaches to the jugular notch of the sternum and the clavicle, and below it passes directly into the thoracic fascia. The superficial fascia, by bifurcating, forms a sheath for the sternocleidomastoid and trapezius muscles and a capsule for the submandibular gland. The superficial fascia is pierced by the above-mentioned cutaneous nerves. The middle fascia (f. colli media) differs from the superficial one by the presence of aponeurotic fibers in its structure. The fasciae, in the opinion of many authors, appear as a result of the movement of organs and muscles, by compaction of the perimuscular tissue, while the middle fascia is formed from muscles that are present in lower animals, in humans they are reduced or preserved in the form of a variant, such as the so-called cleido-hyoid muscle (m. cleido-hyoideus). The middle fascia appears in a very early embryonic period, when the other fasciae are not yet expressed. It is stretched between both scapulo-hyoid muscles, forming a sheath for them. Above it extends to the hyoid bone, below it attaches to the inner surface of the jugular notch of the sternum. This fascia also includes the sternohyoid, sternothyroid muscles (mm. sterno-hyoideus and sterno-thyreoideus). Rouvier divides the middle fascia into two layers: superficial and deep. The superficial layer covers the sternohyoid muscle, while the deep one, looser,

Figure 5. Cross-section of the middle of the Neck (semi-schematic): 1-glottis; 2- m. longus colli; 3- m. oro-hyoideus; 4- m. sterno-cleido-mast.; 5-a. carotis comm.; 6-v. jugul. int. and n. vagus; 7-m. scalenus ant.; 8-mm. scaleni with nn. cervicales; 9-m. scalenus med.; 10-m. trapezius; 11- long muscles of the back; 12-v. jugularis ext.; 13-connective tissue space of the Neck; 14-platysma; 15-pharynx; 16-cart. thyreoid.

covers the sternothyroid and thyrohyoid muscles. In the middle, the middle fascia fuses with the superficial one from the hyoid bone to the lower end of the larynx or to the isthmus of the thyroid gland. Below, both fasciae separate, with the superficial one attaching to the anterior surface and the middle one to the posterior surface of the sternum, to the interclavicular ligament, and to the clavicle. Some authors attribute a certain role to the middle fascia in regulating venous circulation in the Neck. When the scalenohyoid muscles contract, they tense the middle fascia, which in turn prevents collapse and even slightly stretches the veins fused with the fascia: the subclavian and the external and internal jugular veins. The internal organs of the Neck lie against the posterior surface of the middle fascia, separated only by a small amount of loose connective tissue and the sheath of the vascular-nerve bundle. The middle fascia of the Neck fuses with the terminal part of the internal jugular and subclavian veins. The vascular sheath surrounds the main vascular-nerve bundle: a. carotis communis, v. jugularis int., n. vagus, and for each of these structures, the common sheath provides a fibrous connective tissue covering, thanks to which they can be relatively easily separated from each other (fig. 5-8). Along the anterior surface of the vascular sheath passes the descending branch of n. hypoglossi. The internal organs of the Neck-the trachea, esophagus, and thyroid gland-have a common visceral sheath. This sheath upward passes into the peripharyngeal fascia covering the constrictors of the pharynx, and downward extends into the mediastinum. For the thyroid gland, the sheath forms a separate capsule. On the right and left, the common visceral sheath contacts the prevertebral fascia and attaches to the anterior tubercles of the transverse processes of the cervical vertebrae by means of poorly expressed sagittal plates. The latter, together with the prevertebral fascia, limit the so-called visceral space of the Neck. The deep fascia of the Neck, or prevertebral (f. colli profunda, s. praevertebralis) covers the anterior surface of the bodies of the vertebrae and all the prevertebral muscles: the rectus muscle of the head, the anterior and lateral, and the long muscles of the head and neck. This fascia forms sheaths for the listed muscles. The prevertebral fascia extends from the pharyngeal tubercle to the D1 vertebra. Outwardly, it covers the group of scalene muscles and reaches the superficial fascia at the anterior edge of the trapezius muscle. The fasciae of the Neck form a series of interfascial spaces that are important in the spread of inflammatory processes. The superficial fascia participates in the formation of fascial beds for the submandibular gland, parotid gland, and muscles: sternocleidomastoid and trapezius. The fascial bed, or capsule of the submandibular gland, consists of two layers-superficial and deep. The superficial layer, denser, covers the outer surface of the gland. The deep layer, less pronounced, lines the floor of the submandibular fossa. This closed fascial cavity communicates with the sheath of the vascular-nerve bundle of the Neck along the course of the maxillary artery; it also communicates with the submucous connective tissue of the mouth along Wharton's duct. The bed of the parotid gland communicates with the lateral wall of the pharynx and the cervical vascular bundle. Between the beds of the parotid and submandibular glands there is a dense partition.

18-gland, tnyreoidea.

Between the superficial and middle fasciae of the Neck there are two interfascial spaces-the suprasternal and supraclavicular. The suprasternal space (spatium suprasternale) is located above the jugular notch of the sternum. Outwardly, this space on both sides forms a blind pouch (saccus caecus retrosterno-cleido-mastoideus), which are located under the anterior parts of the sternocleidomastoid muscles, parallel to the clavicle. The suprasternal interfascial space is filled with loose connective tissue, in which passes the jugular venous arch or the terminal parts of the median and anterior jugular veins of the neck. The blind pouch is also filled with connective tissue and sometimes contains lymph nodes. It is pierced by the anterior jugular veins, which under the second fascia empty into the subclavian or external jugular veins. The supraclavicular interfascial space (spatium supra-claviculare), superficial and deep, extends from the anterior edge of the trapezius muscle along the clavicle under the sternocleidomastoid muscle (almost to its inner edge).

Figure 7. Horizontal section through the neck below the vocal cords: 1-cart, thyreoidea; 2-m. thyreo-arytaen.; 3-m. crico-arytaen. lat.; i-cart, cri-coidea; 5-pharynx; 6-m. longus colli et capitis; 1-truncus sympath. et a. cervic. ascend.; 8- a. et v. vertebralis; 9-nn. cervicales; 10-in. scalen. med.; H-m. scalen.ant.; 12-m. sterno-cleido-mast.; 13-n.phrenicus;i4-platysma;7 5-a.carot. comm. and d. vagus; 16-v. jugularis int.; 17-ram. descend. n. XII; is-a. thyreoidea sup.; 19-m. sterno-thy-reoid.; 20-m. omo-hyoid.; 21-m. sterno-hyoid.

Between the superficial and middle fasciae is the superficial supraclavicular space; under the second fascia is the deep one. The latter communicates with the axillary cavity. At the outer edge of the sternocleidomastoid muscle, the supraclavicular interfascial space is pierced by the external jugular vein. Between the middle fascia and the internal organs of the Neck-the trachea and thyroid gland, covered by visceral fascia-is the so-called previsceral space (spatium praevis-cerale). The latter is laterally limited by the sheaths of the main cervical vascular-nerve bundle. The vascular sheath here is very thin and does not prevent the spread of inflammatory processes from the previsceral space into the vascular-nerve bed. Medially from the common carotid artery, the previsceral space communicates with the retrovisceral one. The previsceral space downward passes into the anterior mediastinum. In the connective tissue of this space are the thyroid venous plexus (plexus ven. thyreo-ideus impar), sometimes the unpaired thyroid artery (a. thyreoidea ima) and lymphatic formations. The retrovisceral space (spatium retroviscerale) is formed between the pharynx and esophagus in front and the prevertebral fascia behind. The loose connective tissue of this slit creates good conditions for the excursion of the pharynx and esophagus. The retrovisceral space communicates with the sheath of the vascular-nerve bundle, the previsceral space, the posterior mediastinum, into which it directly passes, and along the buccopharyngeal muscle (m. bucco-pharyngeus) with the deep part of the face, with the so-called Bichat's space (Bichat). Finally, the last space is osseofibrous; it is located between the bodies of the vertebrae and the prevertebral fascia. This space corresponds to the extension of the prevertebral fascia, i.e., it extends from the pharyngeal tubercle to the D1 vertebrae. Along this path spread the so-called cold abscesses originating from the bodies of the vertebrae in their tuberculous lesions. The lymphatic system of the Neck is divided into superficial and deep. The superficial lymph nodes are located under the superficial fascia of the Neck in the form of the so-called perivisceral ring of nodes (at the border of the Neck and head) and in the area of the external triangle of the Neck. The perivisceral ring forms a chain consisting of 5 groups of lymph nodes extending from front to back: submental, submandibular, parotid, mastoid, and occipital. The submental group of nodes is located in the submental area and collects lymph from the tissues of the chin, lower lip, middle part of the lower gum, and the tip of the tongue. The submandibular lymph nodes, numbering 6-7 (on average), are located in the submandibular bed and around the gland on its outer and inner surfaces. To them go part of the lymphatic pathways from the eyelids, the entire external nose, cheeks, lips, gums, and tongue. The group of parotid lymph nodes is located entirely under its capsule, at the upper pole, on its outer surface and in the very thickness of the gland. Here flow the lymphatic vessels from the frontal and temporal regions, from both

Figure 8. Horizontal section of the neck at the level of the VII cervical vertebra, demonstrating the location of the aponeurotic system of the neck: 1- spatium substernale; 2-aponeurosis cerv. superf.; 3-v. jugul. ant.; 4-aponeur. cerv. med. (deep layer); 5-apon. cerv. med. (superficial layer); 6-n. hypo-glossus;7-a. carot.comm.;8-v. jugul. int.; 9-apex pulm.; 10-vascular sheath;11-sympathetic node; 12- aponeur. cerv. prof.; 13-sympathetic node; 14- sympathetic node; 15-v. vertebr.; 16-a., vertebr.; 17- vertebral body; 18-m. levat. scapul.; 19-m. trapez.; 20-m. scalen. med. et post.; 21-m. scalen. ant.; 22-v. jugul. ext.; 23-m. praevertebr.; 24-m. omo-hyoid.; 25-spatium retroviscerale; 26-m. sterno-thyreoid.; 27-m. sterno-cleido-mast.;28-m. sterno-cleido-hyoid.; 29-visceral fascial layer.

ey, root of the nose, outer ear, and parotid gland. Into the deep nodes of the gland itself also open lymphatic vessels of the nasal mucosa, angle of the lower jaw, and the last 2 molars. Inflammatory swelling of the parotid lymph nodes, the so-called false parotitis (lymphadenitis glan-dularum parotidis), simulates true parotitis.-The mastoid lymph nodes, numbering 2-3, are located at the beginning of the sternocleidomastoid muscle, near the mastoid process. They collect lymph from the auricle, external auditory canal, and skin of the hairy part of the temporal region.-Finally, the last part of the perivisceral ring is the group of occipital nodes located under the fascia above the semispinal muscle of the head (m. semispinalis capitis). They collect lymph from the hairy part of the skin of the occipital region.-Another part of the superficial lymph nodes of the N. is located within the lateral triangle under the superficial fascia. Lymphatic vessels of the skin and subcutaneous tissue converge to these nodes from in front and behind, with 5-6 trunks on each side. The deep lymphatic system of the N. includes: the deep lateral group of nodes, the perivisceral group, and the common lymphatic trunks.

Figure 9. Division of the neck into regions: 1-m. digastricus (anterior belly); 2-t. mylo-hyoideus; 3- gland, submaxillaris; 4-posterior belly of t. diga-strici; 5-outline of os. hyoidei; 6-incisura thyreoidea; 7-outline of cart. thyreoid.; 8-outline of cart. eric; 9-trachea; 10-clavicula; 11-slit between the two heads of m. sterno-cleido-mast.; 12-m. omo-hyoid. and m. scal. ant. and med.; 13-m. trapezius; 14-m. sterno-hyoideus; 15-m. omo-hyoid; 16-m. sterno-cleido-mast.; 17-m. hyo-glossus; 18-margo inf. mandib.

The deep lateral group has 20-30 nodes located along the entire internal jugular vein. In these nodes, external and internal subgroups are distinguished. The nodes of the internal subgroup are located along the outer edge of the internal jugular vein. Lymph vessels from the chin area, submandibular, parotid, mostly from the tongue, hard and soft palate, nasal cavity, pharynx, esophagus, larynx, trachea, and thyroid gland go to them. Lymph vessels from the neck viscera go partially directly to the mentioned glands, partially through the group of paravisceral nodes. The mentioned nodes also collect lymph from the nasopharynx and middle ear. The nodes of the external subgroup are partially covered by the sternocleidomastoid muscle; mainly they are located behind the outer edge of it in the supraclavicular area (so-called supraclavicular nodes). Lymph pathways from the occiput, shoulder, armpit, axillary area, and from the thyroid gland go to them. The paravisceral group of nodes (lgl. lympha-ticae juxtaviscerales) contains two retropharyngeal nodes, which are located in front of the prevertebral muscles. They receive lymph pathways from the nasal cavity, Eustachian tube, and nasopharynx. One or two nodes (inconstant), located in front of the larynx, collect lymph from part of the larynx. In front of the trachea there are also inconstant nodes, which collect lymph from the trachea and thyroid gland. The suprasternal nodes also belong to these nodes. Along the course of the recurrent nerve, there are nodes that collect lymph from part of the larynx, trachea, esophagus, and thyroid gland. From the paravisceral group of nodes, lymph pathways go to the jugular nodes under the sternocleidomastoid muscle. Ultimately, all lymph pathways of the N. (as well as of the head) go to the lymph nodes along the jugular vein (internal subgroup of deep nodes of the N.). Lymph vessels branching off from these nodes, merging, form on each side a common jugular lymph trunk, single or double. This trunk on the right side of the N. flows into the so-called right venous angle - the place of confluence of the internal jugular vein with the right subclavian vein. On the left, the jugular trunk flows into the thoracic lymph duct (ductus thoracicus). Sometimes the right jugular trunk connects with the supraclavicular and bronchomediastinal trunk, which collect lymph from the upper limb and the upper part of the right half of the thoracic cavity. This trunk after confluence is called the great lymph vein, its length is 1 cm, it flows into the right venous angle. Division of the N. by areas (fig. 9). Topoanat. relationships of the elements of the N., clinical-surgical features, development and spread of pathological processes make it advisable to divide the entire N. into a number of small topoanat. areas. The spine divides the N. into 2 departments: proper N. and occiput (see Occiput). Of particular interest is the proper N., or what Corning calls regio colli sensu strictiore. In the latter, the middle triangle (trigonum colli medium) and two lateral (trigonum colli lat. dext. et sin.) are distinguished. The middle triangle is bounded on the sides by the inner edges of the sternocleidomastoid muscle. Its base is formed by the lower jaw. Its apex lies at the jugular notch of the sternum. The middle triangle is divided by the median line of the N. into 2 symmetrical medial triangles (trigonum colli mediale dext. et sin.). The lateral triangles (see below) have their apices turned upward, each is bounded by the posterior edge of the sternocleidomastoid muscle and the anterior edge of the trapezius. Their base is formed by the clavicle. By the hyoid bone, the middle triangle is divided into 2 areas: the suprazygoid (regio suprahyoidea) and the subzygoid (regio infrahyoidea). The retro-mandibular area is also referred to the suprazygoid area, which other authors refer to the facial area. The suprazygoid area is bounded below by a horizontal line passing through the body of the hyoid bone, above by the edge of the lower jaw. The position and shape of the suprazygoid area change depending on the relationship between the lower jaw and the hyoid bone. With flexion of the head, the lower jaw approaches the hyoid bone, forming with it as it were two arches lying in the same plane. At this time, the entire suprazygoid area is behind the lower jaw. Extension of the head, moving away from the lower jaw and the lower boundary of the suprazygoid (area, strains the muscles lying here and makes the entire area more extensive and accessible to examination. The change in position is used for examination of this area and during surgical operations. In the thickness of the superficial fascia of this area and above it, the cervical branch of the facial nerve (ramus colli n. facialis) runs in a horizontal direction from outside to inside, innervating the subcutaneous muscle. Directly at the edge of the lower jaw passes the marginal branch of the mandibular nerve (ramus marginalis), innervating the square muscle of the lower lip. In the suprazygoid area, the chin (regio submentalis) and 2 submandibular areas (regio submaxillaris) are distinguished. The chin area is bounded by the anterior bellies of both digastric muscles, the body of the hyoid bone, and the lower jaw. Both bellies of the digastric muscle and the edge of the lower jaw form the submandibular triangle (trigonum submaxillare). The floor of the submandibular triangle is formed by the muscles: hyoglossus (m. hyo-glossus) and mylohyoid (m. mylo-hyoideus) (fig. 10). The latter, covering part of the previous one, goes to the middle of the N. in the chin area, where, meeting with the muscle of the same name of the other side, it forms a tendon suture (raphe). This suture goes from the chin bone to the body of the hyoid bone. In the submandibular triangle is located the submandibular gland (see). On the floor of the submandibular triangle there is a slit between the posterior edge of the mylohyoid and hyoglossus muscle, which communicates with the bed of the gland with the cellulose located on the diaphragm of the mouth. Into this slit enters the process of the submandibular gland with its excretory duct, the hypoglossal nerve, and the lingual vein. On the floor of the submandibular triangle is located the Pirogov triangle. Its apex is directed downward, to the tendon part of the digastric muscle. Its base is the hypoglossal nerve, crossing here transversely the hyoglossus muscle and going in the company of the lingual vein. Both lateral walls are formed by the posterior edge of the mylohyoid muscle and the posterior belly of the digastric. In individual cases, the hypoglossal nerve passes directly near the tendon part of the digastric muscle. In these cases, the Pirogov triangle is poorly expressed. The Pirogov triangle has significance for finding and ligating the lingual artery, which passes under the hyoglossus muscle. At the upper border of the submandibular triangle passes the lingual nerve, covered by the lower jaw. The retro-mandibular area (regio retromandibularis) is bounded in front by the ascending branch of the lower jaw and the medial pterygoid muscle, behind by the mastoid process and the sternocleidomastoid muscle, above by the cartilaginous and bony parts of the external auditory canal and the posterior part of the zygomatic arch, below by a line going approximately from the angle of the lower jaw to the anterior edge of the sternocleidomastoid muscle. The retromandibular fossa is filled with the parotid gland, which has very irregular outlines. The capsule of the parotid gland is not everywhere of the same density. It is most dense on the outer surface of the gland. From it, processes extend inward, dividing the gland into separate lobules. In the area of the external auditory canal and the lateral wall of the pharynx, the capsule is extremely weakly expressed. There is very little cellulose between the capsule and the gland. Through the thickness of the gland pass the external carotid artery, external jugular and posterior facial veins, and the facial nerve; all this makes the enucleation of the gland extremely difficult and almost impossible without cutting the structures passing there. The subzygoid area (regio infrahyoidea) represents an isosceles

Figure 10. Muscles of the neck (side view): 1-m. digastricus (venter ant.); 2-m. mylohyoid.; 3-m. digastricus (venter post.); 4-m. hyoglossus; 5-tendon (intermuscular) m. digastrici; 6-constrictor med.; 7-m. thyreohyoid.; 8-m. omohyoid.; 9-m. sternocleidohyoid.; 10-m. scalenus ant.; 11-m. sternomastoid.; 12-m. sternocleidomastoid.; 13-m. cleido-occipital.; 14-m. omohyoid. (venter post.); 15-m. trapezius; 16-m. scalenus med.; 17-m. levator scapulae.; 18-m. sternocleidomastoid.; 19-m. splenius; 20-m. stylohyoid.

a triangle located below the hyoid bone. The apex of the triangle lies in the jugular notch of the sternum. The base is directed upward and is formed by a line drawn at the level of the hyoid bone. The lateral sides are formed by the anterior borders of the sternocleidomastoid muscle. The shape of the subhyoid area is not uniform throughout its entire extent. In its upper part it is convex, forming a series of protrusions here. Below, above the jugular notch of the sternum, it is concave, forming the suprasternal, or jugular, fossa (fossa suprasternalis, s. jugularis). On external examination and palpation, well-defined ridges formed by the anterior borders of the sternocleidomastoid muscles are visible here. Medially from them go corresponding grooves, called by some authors the grooves of the carotid artery. Above, the hyoid bone is palpable. Below it, a prominence formed by the thyroid cartilage is well expressed (especially in men), which is called Adam's apple (pomum Adami, s. eminentia thyreoidea). Between the upper edge of the thyroid cartilage and the hyoid bone is the subhyoid fossa, or groove (fossa subhyoidea). It varies in height from 7 to 3 cm, depending on the position of the head. The more the head is extended, the higher the space between the hyoid bone and the edge of the thyroid cartilage. In the usual position of the head, the height of the subhyoid fossa is 1/2 cm. The floor of the subhyoid fossa is formed by the thyrohyoid membrane (membrana thyreo-hyoidea). The latter is stretched between the upper edge of the thyroid cartilage and the lower edge of the body and greater horns of the hyoid bone. The thyrohyoid membrane is not of the same density everywhere. It is denser in the middle and at the level of the horns, where it acquires the character of ligaments, which are called the median and lateral thyrohyoid ligaments (lig. thyreo-hyoidea med. et lateralia). The anterolateral surface of the membrane is pierced here by the superior laryngeal nerve and the vessels of the same name, passing in a transverse direction from without within. Between the membrane and the covering thyrohyoid muscle is a small layer of loose connective tissue, in the middle of which is located a small serous sac, the so-called Bursa of Bouver. The latter can be the site of development of bursitis and hygromas. Behind the thyrohyoid membrane, between it and the epiglottis, there is a space filled with connective tissue. Below the subhyoid fossa are located the larynx (see), trachea (see), esophagus (see), and thyroid gland (see). The larynx, trachea, and thyroid gland are covered in front and on the sides by the following muscles: sternohyoid, sternothyroid, thyrohyoid, and omohyoid (fig. 11). The latter, with its two bellies, superior and inferior, participates in the formation of 4 triangles: trigonum caroticum, trigonum omotracheale, trigonum omotrapezoides et trigonum omoclaviculare. Trigonum caroticum, s. omohyoideum (triangle of the carotid artery) is bounded medially below by the superior belly of the omohyoid muscle, medially above by its inferior belly, and on the third side by the anterior border of the sternocleidomastoid muscle. Trigonum omotracheale is formed medially by the median line of the neck, laterally above by the superior belly of the omohyoid muscle, and laterally below by the anterior border of the lower part of the sternocleidomastoid muscle. Within the limits of these two triangles, in the area of the sternocleidomastoid muscle, passes the main vascular-nervous bundle. The area of the sternocleidomastoid muscle (regio sternocleidomastoidea) occupies the space between the lateral and median triangles. This area is also called the area of the carotid artery, because the greater part of the latter is medial and under the sternocleidomastoid muscle. The sternocleidomastoid muscle is located in a sheath formed by the superficial fascia. The sheath is more pronounced in the upper third. The sternocleidomastoid muscle consists of two bundles, one above the other. The more superficial bundle, called the sternal head, goes from the lateral surface of the mastoid process and the superior nuchal line obliquely downward and medially, where it passes into a conical tendon attached to the anterior surface of the sternum. The deep bundle, or clavicular head, goes from the mastoid process under the first bundle vertically downward, where it attaches to the medial end of the clavicle. Between both heads of the muscle, at their attachment site, a triangular-shaped fossa (fossa suprascapularis minor) is formed, in the depth of which under the median fascia is the v. subclavia. Starkov describes 4 heads in the sternocleidomastoid muscle: sternomastoid and sternocleidomastoid, clavicular-mastoid and clavicular-occipital. Of these 4 heads, the sternomastoid, sternocleidomastoid, and clavicular-occipital are visible in front. Behind the latter is the clavicular-mastoid. The sternocleidomastoid head is not always expressed. Between it and the clavicular heads is the aforementioned fossa suprascapularis minor. The vascular-nervous bundle consists of the common carotid artery, internal jugular vein, and nerves. It is located medial and under the sternocleidomastoid muscle and is surrounded by loose connective tissue and a vascular sheath. The vascular-nervous bundle extends upward to the base of the skull, and downward passes into the mediastinum. It is bounded medially by the viscera of the neck with their perivisceral sheath, and laterally by the sternocleidomastoid muscle. In the lower third, between the sternocleidomastoid muscle and the vascular bundle, are the omohyoid muscle and the median fascia. Behind, the vascular-nervous bundle lies on the prevertebral fascia, the long muscle of the neck and head. The vascular-nervous bundle is projected onto the surface of the neck along a line connecting the sternoclavicular joint with the midpoint between the angle of the mandible and the mastoid process. In the area of trigonum caroticum, the vascular bundle is located as follows: laterally, the internal jugular vein; medially, the common carotid artery; and between them, the vagus nerve. Along the anterior surface of the artery, descending downward in the thickness of the vascular sheath, is the descending branch of the hypoglossal nerve (ramus descendens n. hypoglossi). At the level of the upper edge of the thyroid cartilage, the common carotid artery divides into the external and internal. Along the external carotid artery also passes, crossing it, the superior laryngeal nerve. The latter arises from the ganglion nodosum. The superior laryngeal nerve divides into 2 branches—internal and external. From the external branch arises the n. depressor cordis. Together with the vagus nerve, from the jugular foramen exit the glossopharyngeal and Willis nerves. The glossopharyngeal nerve passes between the internal carotid artery and the stylopharyngeus muscle (m. stylo-pharyngeus) downward and medially, and then continuing between the stylopharyngeus and styloglossus muscles, reaches the tongue.

Behind the initial part of the internal jugular vein passes the hypoglossal nerve, exiting the skull from the foramen of the same name. The vagus nerve anastomoses with all the aforementioned nerves of the upper part of the vascular-nervous bundle. Behind the bifurcation of the common carotid artery in 12.5% of cases (Marchand) there is a small body, less than 1 cm, called the carotid gland (see); it is intimately fused with the carotid artery. The topographic-anatomical relationships are more complex in the lower part of the neck's vascular-nervous bundle—in the area of the anterior scalene triangle (trigonum scaleno-vertebrale). The latter is bounded laterally by the anterior scalene muscle, medially by the long muscle of the neck. The apex of the triangle is at the level of the tubercle of the transverse process of C_VI vertebra (tuberculum caroticum, s. Chassaignaci). This tubercle serves as the site for pressing the common carotid artery. The base of the triangle is the dome of the pleura (fig. 12). The latter protrudes above the I rib for a distance of 2-5 cm. It is surrounded by a layer of loose connective tissue and has some mobility. Into the dome of the pleura are woven fibers of ligaments going from the angle and neck of the I rib, from the body of C_VI vertebra, and the tendon fibers of the scalenus minimus muscle. The latter, originating from the transverse processes of C_VII and C_VIII vertebrae, passes through the posterior scalene space between the brachial plexus and subclavian artery and approaches the dome of the pleura. The height of the position of the pleural dome changes depending on the position of the head and neck. When the head is bent to the sides, the pleural dome descends on the bent side almost to the I rib and rises on the extended side above the normal level by 1-2 cm. This is explained by the presence of the aforementioned ligaments. Zhory confirmed this in experiments with filling the pleural cavities with plaster in different positions of the head at the Institute of Operative Surgery of the 1st MMI in 1925 (Prof. Burdenko). Changes in the position of the pleural apex have practical importance in anesthesia of the brachial plexus according to Kulenkampff. Kulenkampf recommends maximum abduction of the head to the side opposite the anesthetized brachial plexus. In this case, the pleural dome rises

Figure 12. Ligaments of the pleural dome.

Figure 13. N. phrenicus, formed from C_III-C_V, C_VI.

the transverse processes of C_VII and C_VIII vertebrae, passes through the posterior scalene space between the brachial plexus and subclavian artery and approaches the dome of the pleura. The height of the position of the pleural dome changes depending on the position of the head and neck. When the head is bent to the sides, the pleural dome descends on the bent side almost to the I rib and rises on the extended side above the normal level by 1-2 cm. This is explained by the presence of the aforementioned ligaments. Zhory confirmed this in experiments with filling the pleural cavities with plaster in different positions of the head at the Institute of Operative Surgery of the 1st MMI in 1925 (Prof. Burdenko). Changes in the position of the pleural apex have practical importance in anesthesia of the brachial plexus according to Kulenkampff. Kulenkampf recommends maximum abduction of the head to the side opposite the anesthetized brachial plexus. In this case, the pleural dome rises

Figure 14. A branch from C5 connects with the main trunk of the thoracoabdominal nerve, forming a loop for the v. subclavia.

s 1-2 cm above its normal position and contributes to the most frequent complication - the needle entering the pleura. It is desirable to administer novocaine solution with the head in a normal position, which largely eliminates the possibility of the needle entering the pleural apex. In the area of the anterior scalene fissure or the scalenovertebral triangle, the vascular-nerve bundle is in contact with a number of other vessels and nerves of the neck. The largest of these are the subclavian artery and vein with their branches (see Subclaviae arteria, vena). On the right side, between the venous angle and the subclavian artery, the thoracoabdominal nerve passes, directed into the thoracic cavity - more laterally, and the vagus nerve - medially. The main trunk of the thoracoabdominal nerve passes from top to bottom and from outside to along the anterior surface of the scalene muscle. It usually lies in the form of a single trunk (fig. 13). A subclavian branch is found in 25% of cases. It usually connects with the main trunk of the thoracoabdominal nerve at the level of the I rib and below, forming a loop around the subclavian vein (fig. 14, 15). It has great practical significance (in so-called phrenicectomy) when there is a double thoracoabdominal nerve on the neck. In such anomalies, tearing the nerve without first cutting the additional or subclavian branch can lead to rupture of the subclavian vein, on Figure 15. Two thoracoabdominal nerves from C5 and C6 merge into one main trunk in the thoracic cavity, forming a loop around v. subclavia and the additional

in the form of a loop. (Fig. 15). The right subclavian artery is posteriorly surrounded by the ascending recurrent nerve. On the left side, the subclavian artery is covered by the internal jugular vein and the beginning of the anonymous vein. Behind them also pass the left thoraco-abdominal and vagus nerves. The latter pass into the thoracic cavity along the anterior semicircle of the subclavian artery. The left recurrent nerve lies medial to the beginning of the left subclavian artery. At the venous angle on the right side, the right lymphatic duct opens, on the left - the thoracic lymphatic duct. Behind the vascular-nerve bundle, under or within the substance of the prevertebral fascia, is the cervical sympathetic trunk. According to Sazon-Yaroshevich, the sympathetic trunk is found in two types: the segmental type, having 6 distinct nodes, and the non-segmental type, giving 2 powerful nodes - the upper and lower. Most authors distinguish three nodes: upper, middle, and lower. The upper node lies on the straight anterior muscle of the head at the level of the transverse processes of the C₆ and C₇ vertebrae. From the upper node arise the following branches: to the internal carotid and to the nerves (nn. abducens, oculomotorius, trochlearis, trigeminus, vagus, hypoglossus et phrenicus); from the upper node also arise the upper cardiac branches (rami cardiaci super.). The middle node is not constant, lies at the level of the C_VI vertebra behind the inferior thyroid artery. From the middle node go branches forming the plexus of the common carotid artery, branches to the thyroid gland, to the bronchi, to the heart (middle cardiac branches). In the absence of a middle node, the cardiac nerves depart from the sympathetic trunk between its upper and lower nodes. Between the middle and lower nodes, in front of and behind the subclavian artery, connecting branches pass, forming the so-called subclavian loop (ansa subclavia, s. Vieussenii). The lower node is located in front of the transverse process of the C_VII vertebra and the head of the I rib. It lies behind the vertebral artery. Often fusing with the first thoracic node, it forms the stellate sympathetic node (gangl. stellatum). On the left side, the latter is in very close proximity to the thoracic lymphatic duct. The lateral triangle of the Neck is bounded on the sides by the anterior edge of the trapezius muscle and the posterior edge of the sternocleidomastoid muscle. Its base is the clavicle. The floor of the triangle is formed by the muscles m. splenius, levator scapulae, scalenus medius et anticus. The superficial fascia of the neck covers the entire triangle, in the lower part of which the middle fascia of the neck and the omohyoid muscle are also found. The latter participates here in the formation of 2 triangles. The upper triangle, trigonum omo-trapezoides, is bounded by the trapezius muscle, sternocleidomastoid, and omohyoid. The lower triangle, or supraclavicular fossa, is formed by the inferior belly of the omohyoid muscle, the lower part of the posterior edge of the sternocleidomastoid muscle, and the clavicle. Within the supraclavicular fossa, 2 interfascial spaces are formed - superficial and deep: the superficial between the superficial and middle fasciae and the deep - under the second fascia. The latter communicates with the axilla. In the deep interfascial space of the supraclavicular fossa, the subclavian artery and the brachial plexus pass. Incisions for ligation of vessels on the Neck - see Carotis arteria. Clinic. Injuries to the neck have serious practical significance due to the large number of vital elements which the Neck contains (vessels, nerves, esophagus, trachea, etc.). Among injuries to the skin of the Neck, burns should be specially mentioned, often observed in this area due to its exposure from clothing and leading to extensive scar contractures, which subsequently require repeated plastic operations (see Burns). Punctured and incised wounds of the neck are, as a rule, very severe, and in injuries to large vessels - fatal. Cutting of the neck (usually in suicide attempts) usually leads to damage to the trachea and esophagus, the large vessels often remain untouched in such cases, and these injuries are not always fatal. Gunshot wounds of the Neck - see Field surgery. Branchiogenic fistula of the neck - see Branchiogenic. In the practical work of a physician, inflammatory diseases of the Neck occupy a prominent place. They are not so rare and give a diverse clinical picture depending on the nature of the infection and the paths of spread. The latter, in turn, give different prognoses and require different methods of surgical treatment. We still do not have an exact classification of inflammatory diseases of the Neck. Individual authors distinguish up to 12 types of diseases. Most authors retain the usual division of inflammatory processes into acute and chronic, into inflammatory processes superficial, up to the first fascia of the Neck, and deep. The most frequent causative agents of purulent processes in the Neck are staphylococci and streptococci. More rarely, inflammatory processes are caused by Bac. coli, pneumococci, typhoid bacillus, anaerobes, etc. The introduction of pus-forming infection can occur from the skin and from the mucous membranes of the larynx, trachea, nose, and pharynx. The source of infection can be inflammatory processes of the parotid gland, submandibular, tonsils, carious teeth, mastoid process, perichondritis, etc. Superficial inflammatory diseases of the Neck. These include dermatitis, erysipelas (see), superficial abscesses and phlegmons, furuncles and carbuncles. All these diseases, in terms of clinical course and anatomical spread, do not fundamentally differ from those in other parts of the body. Superficial abscesses and phlegmons are more often secondary diseases, arising as a complication in a number of other diseases of the Neck, face, etc. The treatment of superficial abscesses and phlegmons is surgical and is conducted according to general surgical rules. Among the primary superficial inflammatory processes of the Neck, furuncles and carbuncles are most frequent. The favorite site for the development of the latter is the occipital region. Mechanical irritation of the skin of the occipital region by clothing contributes both to the development and spread of infection. The clinical course of furuncles, especially carbuncles, on the occipital region has certain peculiarities due to the presence of connective tissue bundles going from the skin to the fascia of the trapezius muscle and the very dense cellular tissue. Furuncles and carbuncles of the occipital region cause greater tension of tissues and more severe painful sensations. Carbuncles of the occipital region can reach the size of an adult's fist or larger. In most cases, they give very severe clinical phenomena: high temperature, severe painful sensations in the area of the inflammatory focus, inability to move the head and Neck, and a general severe condition. In individual cases, a carbuncle of the occipital region takes a malignant course, giving severe general intoxication of the body, leading to a fatal outcome in a short time. Characteristic for the carbuncle of the occipital region, as in other parts of the body, is the insufficient tendency to purulent melting of tissues, significant necrosis of the skin and subcutaneous tissue. - Treatment of furuncle and carbuncle of the Neck does not differ from that in other parts of the body (see Carbuncle). Deep abscesses and phlegmons of the Neck. They can be of primary - hematogenous - and secondary - lymphogenous - origin. The latter path is the most frequent. In this case, the development of phlegmons and abscesses of the Neck occurs as follows: infection from a focus on the Neck, face, and other areas is carried along lymphatic pathways into the lymphatic glands, causing lymphadenitis, periadenitis, adenophlegmon or abscess. It is not always possible to detect the port of entry of infection. Cervical phlegmons predominantly affect young age - 15-30 years. The right and left sides are affected equally often. In 530 cases, Poulsen observed 242 lesions of the right side of the Neck, 243 of the left, and 130 of the middle of the Neck. The male sex suffers somewhat more often than the female. Deep phlegmons and abscesses of the Neck are classified according to the areas of their spread into III, namely: submandibular phlegmon, submental phlegmon, vascular space phlegmon, area of the sternocleidomastoid muscle, pre- and postvisceral. It is necessary to emphasize that such a division cannot always be strictly carried out, since the purulent process spreads very quickly, occupying a series of topographic areas of the Neck. According to Poulsen's statistics, the submandibular area is affected in 47% of cases, the vascular space - in 22%. Other interfascial spaces and departments of the Neck are rarely affected. The submandibular area is the most common site for the development of inflammatory processes. In the submandibular area, inflammation of the lymph nodes located along the edge of the lower jaw under the first fascia is found. Infection into these glands comes along lymphatic pathways from the lower eyelids, nose, cheeks, lips, and gums. Abscesses and phlegmons of this area are often of odontogenic origin and develop as a complication in osteomyelitis of the lower jaw. In individual cases, phlegmon of the submandibular area develops as a result of the transfer of infection from the retromandibular fossa along the posterior belly of the digastric muscle and from the area of the mastoid process incisure in the so-called Bezold's form of mastoiditis.

Abscesses and phlegmons of the submandibular area can spread along the course of Wharton's duct into the tissue surrounding the sublingual salivary gland and into the interfascial spaces communicating with the submandibular area. Pus can penetrate along the course of Wharton's duct to the tissue of the floor of the mouth and cause inflammatory phenomena and infiltration there. Infiltration and pus can penetrate into the tissue surrounding the sublingual salivary glands when the m. mylohyoideus is destroyed. The transition of the purulent process from the submandibular to the parotid area is rarely observed, as there is a dense fascial partition between them. Nevertheless, such transitions are observed in clinical practice (Lukomsky). The development and transition of the inflammatory process into the vascular bed are possible along the anterior facial vein, the external maxillary artery, however such a transition is rarely observed. Submandibular phlegmon gives a clearly defined clinical picture: high temperature, limitation of movement of the Neck and head, foetor ex ore, painful opening of the mouth and painful process of chewing. In addition, there is a clearly expressed swelling of the submandibular area. When the process spreads into the oral cavity, infiltration and swelling appear in the alveolo-lingual sulcus on the floor of the oral cavity. With continuation of the process downward, swelling appears above the upper part of the sternocleidomastoid muscle in the trigonum caroticum. The skin in submandibular phlegmons and abscesses is rarely involved in the process. The dense sheet of the superficial fascia blocks the path of pus outward. The rupture of the abscess into the oral cavity is observed, at which time there is significant relief of painful phenomena, however, the rupture of pus into the oral cavity rarely leads to complete recovery. The prognosis in submandibular phlegmons is very serious and depends on the virulence of the infection, the degree of spread of the process, and the general condition. In severe cases, sepsis develops and fatal outcome occurs. The only means that can to a certain extent prevent a series of severe complications is early surgical intervention. Indeed, with early intervention, it is not always possible to find pus, and sometimes only a purulent-like liquid is found, nevertheless the incision brings significant relief due to the reduction of tension. At the same time, the path along which pus soon begins to be discharged is outlined. Phlegmon of the vascular space. In terms of frequency of involvement in the inflammatory process, the second place is occupied by the vascular bed. Abscesses and phlegmons of this area can be primary and secondary. In the development of the latter, angina plays a dominant role. Poulsen in 117 phlegmons in 62 cases observed angina. The source of infection can be the most diverse inflammatory processes of the head and Neck. The clinical picture of phlegmons of the vascular space is directly dependent on the degree of spread of the phlegmon. Pus from the vascular cleft can spread to the supraclavicular area, the axillary fossa, and descend into the mediastinum. In individual cases, the pre- and retrovisceral spaces are involved in the purulent process. Very rarely, the inflammatory process from one side crosses over to the other side through the visceral spaces. The spread of phlegmon to the other side gives a very poor prognosis. Dupuytren calls this kind of phlegmon H. wide phlegmon ('phlegmon large du cou'). The most severe complication of vascular phlegmons and abscesses is the ulceration of large vessels of the Neck and bleeding. The latter can be fatal. The clinical manifestations of phlegmon of the vascular cleft depend on the spread of the process and the virulence of the infection. Phlegmon of the upper part of the vascular cleft is detected by swelling in the trigonum caroticum behind the angle of the lower jaw. This swelling continues into the submandibular area, the area of the parotid gland, and downward to the larynx. From the side of the oral cavity, a painful swelling is detected at the tonsils. At the same time, disorders of the act of swallowing and breathing may be observed. To alleviate painful sensations from the sternocleidomastoid muscle, the patient holds the head tilted toward the affected side. High temperature, septic condition accompany the described picture, the prognosis with spread of the process is poor. Here, as with submandibular phlegmons, in many cases surgical intervention prevents further spread and leads to a favorable outcome. - Mental phlegmon. Diseases of the oral cavity, teeth, lower jaw, its mental part, and the lower lip can serve as starting points for the development of mental phlegmon. The latter, occupying the area of the Neck from the chin to the hyoid bone and resembling in its picture angina Ludovici, can also spread to the submandibular areas. The clinical picture differs little in its manifestations from the described phlegmons of the Neck. Acute inflammatory processes of the pre- and retrovisceral spaces are relatively rare. In the previsceral space - between the middle fascia of the Neck and the underlying trachea and thyroid gland - acute lymphadenitis of lymph nodes collecting lymph from parts of the larynx, trachea, and thyroid gland are encountered. Infiltrates, phlegmons, and abscesses of this area can develop here with thyroiditis per continuitatem. As already said, pus from the previsceral space can descend into the space of the neurovascular bundle, the suprasternal space, and the anterior mediastinum. From clinical symptoms, with significant spread of the process, disturbance of breathing is very early noted. Among the inflammatory processes of the retrovisceral spaces between the esophagus, trachea, and prevertebral fascia, the most common are inflammations of the retropharyngeal lymph nodes. The retropharyngeal abscesses developing here cause a severe clinical picture, mainly due to disturbance of breathing and swallowing. Sometimes dyspnea, asphyctic attacks are noted due to accumulation of mucus at the entrance to the larynx and increasing edema. In case of suspicion of a retropharyngeal abscess, it is necessary to perform examination through the mouth. At this time, on the posterior wall of the pharynx, a soft-elastic consistency, very painful to the touch swelling is visible. Pus from the retropharyngeal space, with untimely surgical intervention, can penetrate into the vascular cleft and mediastinum. The inflammatory processes described above are the most frequently encountered. It goes without saying that acute inflammation can be in any part of the Neck. A limited abscess or phlegmon of the Neck gives a characteristic clinical picture, already described above. A diffuse purulent process causes a very severe clinical picture. Indeed, diffuse phlegmons can be more benign and less benign. The latter very soon give a picture of sepsis leading very quickly to death. Surgical treatment of abscesses and phlegmons is carried out according to the principles accepted in surgery. Incisions on the Neck are made depending on the topographic location of the phlegmon. For phlegmons of the submandibular area, the incision is made along the swelling 2-3 cm below the edge of the lower jaw. At the same time, it is necessary to avoid cutting the g. marginalis n. facialis passing here. With very large swelling, the incision should be made 4-5 cm below the edge of the jaw as cosmetically more advantageous, since with reverse development and elimination of the process, the scar with such an incision is hidden under the edge of the jaw. With a widespread phlegmon occupying the entire suprahyoid area, an incision of the Neck can be made from the ear (below) to the middle of the Neck. In individual cases, a series of small incisions can be made. Phlegmons and abscesses of the vascular cleft are opened either along the anterior or posterior edge of the sternocleidomastoid muscle. The superficial tissues are cut with a knife: skin, subcutaneous tissue and the primary fascia of the Neck. Further penetration to the abscess is only permissible by the blunt way - with closed scissors or forceps. To avoid the development of bedsores of the vascular wall in the postoperative period, drainage should not be used, limited to loose tamponade. When the phlegmon of the vascular cleft spreads to the retro- and previceral spaces, to the sheath of the sternocleidomastoid muscle and the supraclavicular fossa, when a dense infiltrate occupies half of the neck, wide multiple incisions are necessary. Küttner for phlegmons of the upper part of the vascular sheath recommends an incision along the anterior edge of the sternocleidomastoid muscle. At the mastoid process, the incision bends backward. At the same time, the beginning of the muscle at the mastoid process is separated. De Quervain begins the incision at the mastoid process and along the anterior edge of the same muscle to the clavicle, where he continues the incision outward. The sternocleidomastoid muscle is severed at the sternum and clavicle and turned away. The De Quervain incision widely exposes the lower part of the vascular space. Phlegmons and abscesses of the retrovisceral space are opened by an incision along the anterior edge of the sternocleidomastoid muscle. Vessels are pushed aside with a blunt hook outward, the thyroid gland, sometimes together with the trachea and esophagus, is pulled inward, after which the retrovisceral abscess is opened. For free access, ligation and cutting of the superior, and sometimes inferior, thyroid vessels is sometimes inevitable.

If the abscess is located in the upper part behind the pharynx, it is opened through the oral cavity. In purulent processes in the retrovisceral space, incisions are made either longitudinal along the middle of the Neck or transverse over the inflammatory focus. In case of breathing difficulties, tracheotomy is sometimes indicated simultaneously with the incisions. Cervical lymphadenitis occurs very frequently. The most common cause of these are infectious diseases of the tonsils, angina, and dental diseases. Acute lymphadenitis is characteristic mainly of childhood and accompanies a number of childhood infectious diseases. Acute lymphadenitis is clinically manifested by swelling of the lymph node and the appearance of pain. When a whole group of nodes is affected, they fuse together, forming painful packets. In unilateral lymphadenitis, swelling appears on the corresponding side of the Neck, while in bilateral lymphadenitis, the configuration of the Neck changes depending on the location and extent of the process. Within a few days, acute inflammatory phenomena may disappear. The glands decrease in size and become painless. In other cases, necrotic areas and pus appear in the lymph nodes. In superficial lymphadenitis, periadenitis, and their complications, local phenomena are well expressed. As the process progresses, fluctuation appears, an abscess forms (lymphadenitis abscedens), and the pus breaks through to the outside through the skin. In lymphadenitis of the deep group of cervical glands - jugular, juxtavisceral, etc. - local phenomena are less expressed, and ruptures of purulent-inflammatory nodes to the outside occur much less frequently. Deep purulent lymphadenitis is complicated by periadenitis and deep phlegmonas of the Neck. Lymphadenitis without suppuration is treated only conservatively. The appearance of fluctuation in the node is an indication for surgical intervention - an incision to evacuate the pus. Chronic inflammatory processes of the Neck. Among chronic inflammatory processes, the most common disease of the Neck is chronic lymphadenitis. The latter gives an extremely diverse clinical and patho-anatomical picture. The Neck is exceptionally rich in lymph nodes: of the 800 lymph nodes present in the human body (Starr), 300 nodes are located on the Neck in its various parts. This alone shows what diversity can be observed in the case of node involvement depending on the location of the affected node, the extent of the process, the nature of the infection, etc. Simple chronic lymphadenitis (lymphadenitis chron. simplex) includes such inflammatory diseases of the lymph nodes, which in their nature and course differ from malignant lymphomas and from specific tuberculous and syphilitic lymphadenitis. Chronic lymphadenitis occurs in various areas of the Neck, affecting individual nodes or an entire group of nodes. The inflammatory process is usually limited to the gland itself, rarely giving periadenitis and adhesions between the glands (packets) and with the surrounding tissues, without showing a tendency to suppuration. The patho-anatomical picture in chronic lymphadenitis indicates simple hyperplasia of the cellular elements of the node. The causative agent of the inflammatory process is not always possible to detect. This indicates that the causative agent may not only be bacteria but also their toxins. The portal of entry for infection cannot always be established. The source of infection can be dental diseases, chronic catarrhs of the nasopharyngeal and oral mucosa, chronic angina, chronic inflammation of the middle ear, and diseases of the facial skin (furunculosis, herpes). Carious teeth have special significance in the development of chronic lymphadenitis. Stark found in children in 80% of cases of chronic lymphadenitis, dental lesions, and in 40% other causes were also found, in 40% caries was the only cause of chronic lymphadenitis. Lexer and others, through very careful experiments on animals, established the possibility of infection entering the lymph nodes through healthy mucosa. Chronic lymphadenitis is observed at any age, however, it is most common in children as a consequence of childhood diseases (measles, scarlet fever, diphtheria, etc.). Vollandt found in school-age children in almost 90% of cases enlarged lymph nodes, the majority of which were affected by chronic lymphadenitis. For differential diagnosis, it is first necessary to exclude malignant lymphoma and tuberculosis. Both of these diseases initially proceed as simple chronic lymphadenitis. The treatment of chronic lymphadenitis consists first of all in eliminating the source of infection (diseased teeth, tonsils, chronic runny nose, etc.). In children, it is especially important to establish the appropriate hygienic regime and general strengthening treatment. Locally, mercury ointment and iodine ointment can be applied. Tuberculous lymphadenitis (lymphadenitis tuber-culosa), The main route for the penetration of the tubercle bacillus into the lymph nodes of the Neck is the route through the upper respiratory tract and the initial part of the digestive tract - the pharynx, the cervical part of the esophagus. Tuberculous infection can penetrate the lymph nodes also through intact mucosa and skin. The tubercle bacillus enters the cervical lymph nodes mainly via the lymphatic vessels. The hematogenous route is less common. Foci of tuberculous infection are in various areas of the face, nasopharynx, and Neck. Frankel, Cornet, Straus and others found tubercle bacilli on the nasal mucosa of healthy people in contact with and surrounded by tuberculous patients. Unger and Stark found Koch's bacilli in carious teeth. Orth found tbc bacilli on the tonsils of children who died from diphtheria. Dielafoy found tubercle bacilli in tonsils removed for hypertrophy 8 times in 61 cases. Tuberculous lymphadenitis occurs at any age, mainly affecting childhood and adolescence: according to Fischer, 78.34% of all cases fall in the age group up to 25 years. The percentage of diseases by age is based on Fischer's examination of 1,484 cases as follows: Age Number Percent Age Number Percent 1-5 6-10 11-15 16-20 21-25 26-30 59 120 233 469 282 130 3.96 8.08 15.70 31.60 19.00 8.76 31-35 36-40 41-45 46-55 56-66 63 43 25 29 18 4.25 2.89 1.68 1.95 1.21 The lymph node, after a more or less long incubation period, reacts to tuberculous infection differently in all cases. According to the patho-anatomical picture, three forms of tuberculous lymphadenitis are distinguished. The first is the initial form (so-called lymphoid stage - Bartel), the second form is the development of tuberculous nodules, and the third is diffuse cellular hyperplasia. In the first, initial form, nothing specific for tuberculosis can be found. The lymph node is enlarged, under the microscope enlarged follicles, swelling of endothelial cells, hyperplasia of lymphoid tissue are visible. Tuberculosis in this form is established on the basis of biological reactions by inoculation on animals. The second form differs in that single tuberculous nodules develop in the lymph node. In this form, the process can stabilize, not giving any changes for a long time, and complete healing can occur. As the process progresses, the tuberculous nodules fuse. In the tuberculous foci, areas of caseous degeneration are found. The latter are surrounded by a connective tissue capsule, become calcified and ossified. Active tuberculous bacilli are usually not found in ossified foci. The caseous areas may soften, suppuration and fistulas with specific, characteristic of tuberculosis discharge appear. The third form is expressed by diffuse large-cell hyperplasia. In the affected lymph node, foci and proliferation of epithelioid cells appear, and giant cells can also be found. The normal tissue of the gland is displaced. The lymph nodes reach significant sizes, up to the size of a chicken egg. Caseous degeneration does not occur in most cases of this form of tuberculous lymphadenitis, the process proceeds more or less benignly. With further development, caseous degeneration, softening, and suppuration may still occur. Some authors (Baumgarten) distinguish 4 forms, others (Abricosov) - 2 initial forms of tuberculous lymphadenitis. The described patho-anatomical forms give a diverse clinical picture. In some cases, the glands are little sensitive, not adhered to the skin or deep-lying tissues, in others - they are immobile, adhered to each other and surrounding tissues (muscles, vessels). The tuberculosis-affected nodes have different consistencies - from semi-soft to cartilaginous. Softening and suppuration ultimately lead to the formation of fistulas. Treatment. In tuberculous lymphadenitis, general treatment plays a dominant role. Rational nutrition, climate, conditions (mountain climate, stay by the sea) raise the body's nutrition. Heliotherapy in tuberculous lymphadenitis gives a good effect, better than in all other forms of tuberculosis. The so-called artificial mountain sun - mercury-quartz lamp in the form of general irradiation and local in the area of affected glands - is highly regarded. In recent years, radiotherapy of tuberculous lymphadenitis has been successfully developing. Iselin and Kinbock attribute to X-rays the ability to neutralize tuberculous foci. X-rays destroy tuberculous-affected tissues of the lymph nodes, promoting the development of connective tissue. In the diffuse hyperplastic form of tuberculous lymphadenitis, X-rays enhance resorption.

The duration of X-ray treatment varies from 3-12 months (Wetterer, Rapp, and others). X-rays have no effect on large caseous masses located deep in the Neck. When there are fistulas that do not respond to X-ray treatment, curettage of the fistula with all granulations and disintegrating masses is recommended. For abscesses that do not resolve, aspiration of pus and filling of the cavity with a 5-10% iodoform emulsion is advisable. Surgical treatment is now almost entirely abandoned. Radical removal of all glands affected by tuberculosis is almost impossible. In the presence of periadenitis and large clusters of glands, removal of the glands presents certain difficulties and the danger of injuring large vessels of the Neck. The number of recurrences with surgical treatment significantly exceeds the number of recurrences with conservative treatment ^:-X-rays, quartz, sunlight, etc. Izelin obtained 9% recurrences with X-ray treatment, Disson even less-3.8%; Bios had 28% distant recurrences with surgical treatment. Radical surgical intervention in tuberculous lymphadenitis is permissible only in exceptional cases when conservative treatment is ineffective, when local changes are progressing, and when a number of phenomena threatening the normal function of the neck organs appear. Lymphadenitis luetica, syphilitic lymphadenitis, is observed in all stages of syphilis. With primary lesions of the lips, tongue, and tonsils, the submandibular and submental lymph nodes are affected. The lymph nodes are enlarged, painful, and little mobile due to the development of periadenitis. In secondary syphilis, the glands are dense and show no tendency to enlarge. Tertiary syphilis causes significant enlargement of the nodes, large tumors-lymphomas, often resembling malignant neoplasms. The diagnosis in such cases is not easy. Treatment is anti-luetic.-Actinomycosis. Of all parts of the human body, the Neck is most frequently affected by actinomycosis. According to a number of authors*, the face and Neck are affected in 80%, and the Neck proper in 50% of cases (Tikhov). Carious teeth primarily serve as the gateway for the actinomycosis pathogen. Israel and Partsch discovered the ray fungus in carious teeth. Small wounds, ulcerative processes of the nasopharyngeal mucosa can also serve as a site of penetration for the ray fungus. A characteristic feature of actinomycosis of the Neck is its chronic course, dense, woody swelling; temperature remains normal, painful sensations are absent or minimal. The swelling slowly increases at the periphery. After a certain period of time, sometimes very long, areas of softening appear, pustules develop, which rupture. The walls of abscesses and fistulas are covered with gelatinous, tenacious, pale pink granulations. The process is not eliminated by the rupture of pustules. The woody infiltration continues at the periphery, sometimes deeper. New pustules and subsequently fistulas appear again. A dense infiltrate with unclear demarcation from healthy tissues, with fistulas and characteristic discharge is so characteristic of actinomycosis that the diagnosis is made without particular difficulty. Finding the fungus completes all necessary examinations. In individual cases, the diagnosis is more difficult. This primarily concerns cases with acute course and with mixed infection. Among medicinal agents, special importance is attached to treatment with iodine preparations-in this case, up to 3.0-6.0 grams of potassium iodide per day is given. Brutz achieved complete cure with iodine therapy in 9 cases out of 13, Meyer-in 18 cases out of 23. An excellent result was achieved with combined treatment with iodine and X-rays (Melchior, Jungling, and others.). Jungling gives potassium iodide up to 100 cm³ in a 10:300 solution. Potassium iodide can be administered in the form of injections of 1-3 cm^% of a 1% solution. Sometimes in cases not responding to X-ray treatment, wide incision can be resorted to, followed by X-ray treatment and iodine therapy. Woody phlegmon of the Neck. To chronic inflammatory processes of the Neck belongs the disease described by Reclus under the name of woody phlegmon (phlegmon ligneux du cou). The causative agent of this disease is considered to be staphylococcus and streptococcus. Riccinini found Bacillus fusiformis Vincenti. A characteristic feature of woody phlegmon is the slow (months) development of a very dense infiltrate occupying a considerable space. The process proceeds almost without any inflammatory phenomena, without fever. In the thickness of the swelling, after a more or less long period of time, foci of softening and pustules appear, not always easily detectable. Treatment is little effective, and when pustules appear, small incisions are necessary. Among benign tumors on the Neck, lymphangiomas, angiomas, atheromas, hygromas (from bursa subhyoidea, suprahyoidea), echinococcal cysts, fibromas, neurofibromas, neurinomas, lipomas (sometimes reaching colossal sizes here), enchondromas (originating from cervical vertebrae, clavicle, sternum, first rib), teratomas are observed. A separate place is occupied by rarely occurring tumors of the glandulae carotis (see Carotid gland). Treatment is surgical.-Among malignant tumors of the neck, first of all, tumors originating from lymph glands should be mentioned: aleukemic lymphadenia, lymphogranulomatosis, lymphosarcoma (see). Among tumors of epithelial nature-bronchogenic carcinoma, as well as metastases of carcinoma of various organs to the lymph glands of the neck and supraclavicular space (the so-called Virchow's gland).