Neck

Neck

• The neck is divided into anterior and posterior triangles by ). the sternocleidomastoid muscle. The anterior triangle extends from the inferior border of the mandible to the sternum below and is bounded by the midline and the posterior border of the sternocleidomastoid muscle. The posterior triangle extends backwards to the anterior border of the trapezius muscle and inferiorly to the clavicle. The upper part of the anterior trian - gle, above the hyoid bone, is commonly subdivided into the submandibular triangle above the digastric muscle bellies, and the submental triangle anteriorly , between the anterior digas - tric bellies of each side. The lympha tic drainage of the head and neck is of considerable clinical importance ( Figure 52.8 ). The most important chain of nodes are the jugular nodes, which run adjacent to the internal jugular vein. The other main groups are the submental, submandibular, pre- and postauricular, occipital and posterior triangle nodes. A system of levels is used to describe the location of these neck nodes ( Figure 52.9 ). Of particular note are the jugular nodal levels, which include levels II, III and IV; these relate to the upper, middle and inferior third of the carotid sheath, respectively . The level II nodes, which contain the large jugu lodigastric node, drain the naso- and oropharynx, including the tonsils, posterolateral aspects of the oral cavity and the Level I Level VI the most common sites of enlargement and ma y be palpated along the anterior border of the sternocleidomastoid muscle. Metastatic spread of squamous cell carcinoma (80% of head and neck cancers) most commonly occurs from tumours arising in the upper aer odigestive tract mucosa, which com - prises the following sites: oral cavity , nasopharynx, orophar - ynx, larynx and hypopharynx. When an enlarged neck node is detected and malignant disease is suspected, these sites must be carefully examined.

nodes Jugulodigastric nodes Submental nodes Upper deep cervical nodes Submandibular Jugulo-omohyoid nodes node Supraclavicular nodes Figure 52.8 Distribution of cervical lymph nodes. Figure 52.9 The level system for describing the location of lymph nodes in the neck. Level I, submental and submandibular group; level II, upper jugular group; level III, middle jugular group; level IV, lower jugular group; level V, posterior triangle group; level VI, anterior compartment group; level VII, superior mediastinal nodes. (Reproduced with permission from Watkinson JC, Gilbert RW. surgery and oncology , 5th edn. Boca Raton, FL: Hodder Arnold/CRC Press, 2012.)

Neck

The patient should be examined in the sitting position with the whole neck exposed so that both clavicles are clearly seen. The neck is inspected from the front and the patient asked to swallow , preferably with the aid of a sip of water. Movements of the larynx and any swellings in the neck are noted. The patient should be asked to protrude the tongue if there is a midline neck swelling, as a thyroglossal duct cyst will move upwards with the tongue protrusion. The neck is then examined from behind, one side at a time, with the chin flexed slightly downwards and the neck tilted to the same side being palpated to remove any undue tension in the strap muscles, platysma and sternocleidomastoids. On examining for a lump in the neck, it is often helpful to ask the patient to point to the lump first. Ask if the lump is tender. All five palpable neck node levels (I–V) should be examined systematically . If malignancy is suspected (hard, irregular or fixed to ov erlying skin or to deep structures), inspection of the upper aerodigestive tract mucosa, as described above, is mandatory . Neck

• The neck is divided into anterior and posterior triangles by ). the sternocleidomastoid muscle. The anterior triangle extends from the inferior border of the mandible to the sternum below and is bounded by the midline and the posterior border of the sternocleidomastoid muscle. The posterior triangle extends backwards to the anterior border of the trapezius muscle and inferiorly to the clavicle. The upper part of the anterior trian - gle, above the hyoid bone, is commonly subdivided into the submandibular triangle above the digastric muscle bellies, and the submental triangle anteriorly , between the anterior digas - tric bellies of each side. The lympha tic drainage of the head and neck is of considerable clinical importance ( Figure 52.8 ). The most important chain of nodes are the jugular nodes, which run adjacent to the internal jugular vein. The other main groups are the submental, submandibular, pre- and postauricular, occipital and posterior triangle nodes. A system of levels is used to describe the location of these neck nodes ( Figure 52.9 ). Of particular note are the jugular nodal levels, which include levels II, III and IV; these relate to the upper, middle and inferior third of the carotid sheath, respectively . The level II nodes, which contain the large jugu lodigastric node, drain the naso- and oropharynx, including the tonsils, posterolateral aspects of the oral cavity and the Level I Level VI the most common sites of enlargement and ma y be palpated along the anterior border of the sternocleidomastoid muscle. Metastatic spread of squamous cell carcinoma (80% of head and neck cancers) most commonly occurs from tumours arising in the upper aer odigestive tract mucosa, which com - prises the following sites: oral cavity , nasopharynx, orophar - ynx, larynx and hypopharynx. When an enlarged neck node is detected and malignant disease is suspected, these sites must be carefully examined.

nodes Jugulodigastric nodes Submental nodes Upper deep cervical nodes Submandibular Jugulo-omohyoid nodes node Supraclavicular nodes Figure 52.8 Distribution of cervical lymph nodes. Figure 52.9 The level system for describing the location of lymph nodes in the neck. Level I, submental and submandibular group; level II, upper jugular group; level III, middle jugular group; level IV, lower jugular group; level V, posterior triangle group; level VI, anterior compartment group; level VII, superior mediastinal nodes. (Reproduced with permission from Watkinson JC, Gilbert RW. surgery and oncology , 5th edn. Boca Raton, FL: Hodder Arnold/CRC Press, 2012.)

Neck

The patient should be examined in the sitting position with the whole neck exposed so that both clavicles are clearly seen. The neck is inspected from the front and the patient asked to swallow , preferably with the aid of a sip of water. Movements of the larynx and any swellings in the neck are noted. The patient should be asked to protrude the tongue if there is a midline neck swelling, as a thyroglossal duct cyst will move upwards with the tongue protrusion. The neck is then examined from behind, one side at a time, with the chin flexed slightly downwards and the neck tilted to the same side being palpated to remove any undue tension in the strap muscles, platysma and sternocleidomastoids. On examining for a lump in the neck, it is often helpful to ask the patient to point to the lump first. Ask if the lump is tender. All five palpable neck node levels (I–V) should be examined systematically . If malignancy is suspected (hard, irregular or fixed to ov erlying skin or to deep structures), inspection of the upper aerodigestive tract mucosa, as described above, is mandatory .