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Background Endoscopic thyroidectomy is widely performed as it does not result in neck scar. However, there is a paucity of reports pertaining to completely endoscopic lateral neck dissection (LND). In this study, we introduce our step-wise approach for performing endoscopic selective LND via the chest–breast approach. We refer to this approach as Qin’s seven steps. Methods The Qin’s seven steps are: (1) establishment of working space range; (2) dissection of lymph nodes between the SCM and the sternohyoid muscle (level IV) and exposure of omohyoid; (3) dissection of lymph nodes at level IV; (4) dissection of lymph nodes at level III; (5) dissection of lymph nodes at carotid triangle (level III); (6) exposure of accessory nerve and dissection of lymph nodes at level II a; (7) dissection of lymph nodes at level II b. We reviewed the clinical data of 35 patients with papillary thyroid cancer (PTC) who were operated using the Qin’s seven steps. Results All 35 patients successfully underwent LND; bilateral LND was performed in 5 patients. The mean tumor size was 1.8 ± 1.0 cm; seven patients had multiple lesions. The mean number of retrieved lymph nodes in level II, III and IV were 8.8 ± 5.6, 6.1 ± 4.0 and 9.3 ± 5.1, respectively. As for complications, there were 3 cases of accessory nerve injury and 1 case of hypoglossal nerve injury. Internal jugular vein injury, cervical plexus injury and lymphatic leakage occurred in 2, 7, and 1 patients, respectively. Conclusion The Qin’s seven steps for performing endoscopic selective LND could be safely used in PTC patients with lateral lymph node metastasis. Satisfactory results were achieved in the short-term follow-up period. We recommend the use of Qin’s seven steps for PTC patients who are not desirous of neck scar.

OBJECTIVE The aim: To elaborate the thermosemiotics of acute and chronic tonsillitis during exacerbation. PATIENTS AND METHODS Materials and methods: 48 patients with acute tonsillitis and 19 patients with chronic tonsillitis were examined during disease exacerbation. Thermographic examination was carried out by the medical thermometer TI-120. Statistical processing of data was carried out with computer program "Microsoft Excel" and "Statistica for Windows" v. 6.0, StatSoft Inc. (USA). RESULTS Results: Symmetry, homogeneity and isotherm are normal thermographic features of the skin. Presence of hyperthermia in carotid triangle, on the palms were revealed in patients with acute tonsillitis. In chronic tonsillitis in the stage of exacerbation, a moderate overall «warming up» of the neck and projections of the submandibular lymph nodes was also observed. The average temperature indices of the knee joints were statistically significantly higher than the corresponding values in healthy people °C (P

Ronald Seidel,1 Andreas Wree,2 Marko Schulze3 1Asklepios Medical Center, Department of Anesthesiology and Intensive Care, Schwedt, 16303, Germany; 2Rostock University Medical Center, Institute of Anatomy, Rostock, DE-18057, Germany; 3Bielefeld University Medical Center OWL, Working Group 3: Anatomy and Cell Biology, Bielefeld, DE-33501, GermanyCorrespondence: Ronald SeidelAsklepios Medical Center, Department of Anesthesiology and Intensive Care, Am Klinikum 1, Schwedt, 16303, GermanyTel +49 3332 534521Email ronald-seidel@t-online.dePurpose: Sensory innervation in the carotid triangle involves the cervical plexus, cranial nerves, and the sympathetic trunk. This innervation also applies to skin incision, including various anatomical structures with potentially different innervation, such as the skin (dermatomes), the platysma (myotomes), and the superficial layer of the cervical fascia (fasciotomes), as well as retromandibular retractor insertion (co-innervation: V, VII). The aim of this anatomical study was to develop an injection technique for carotid endarterectomies to additionally block anastomoses between the transverse cervical nerve (TCN), the cervical branch VII (CB VII), and the marginal mandibular branch VII (MMB VII). These anastomoses are also termed superficial cervical ansa (SCA).Materials and Methods: Preparations (n=16) were performed on unembalmed donor cadavers (n=8). Subplatysmal injections (each using 5 mL of Alcian blue) were performed cranially within the carotid triangle between the anterior margin of the sternocleidomastoid muscle and the submandibular gland.Results: Anastomoses between the TCN, CB VII, and MMB VII were stained in all preparations (n=16).Conclusion: This anatomical study presents an ultrasound-guided subplatysmal SCA block to optimize, in addition to a cervical plexus block, the quality of anesthesia for carotid endarterectomies.Keywords: internal carotid artery stenosis, cervical plexus block, regional anesthesia, ultrasonography, facial nerve block

Optic carotid and carotid oculomotor triangles are the main corridors for reaching sellar and parasellar lesions...

A 15-year old female patient was complaining from swelling in the left side of the neck since 3 months. Physical examination showed palpable and mobile left supraclavicular neck mass in the carotid triangle, uvula deviation to the left side and normal vocal cords position and function. Neck imagings showed well-defined, well-encapsulated left neck mass in the left carotid sheath pushing the internal jugular vein anteriorly and the common carotid artery posteriorly. The mass was extending from the level of C4 superiorly and the supraclavicular region inferiorly. Patient was operated with left anterior approach and circumferential dissection and enucleation was performed. Post-operative period was uneventful and devoid of any complications or deficits. Histopathological examination revealed Castleman disease.

Background and objectives: Ultrasound-guided intermediate cervical plexus block with perivascular local anesthetic infiltration is an established anesthetic procedure for carotid endarterectomy. In this prospective pilot study an additional subplatysmal block of the superficial ansa cervicalis is presented for the first time. The target structures are the anastomoses between the facial nerve (cervical and marginal mandibular branches) and cervical plexus. Methods: An ultrasound-guided intermediate cervical plexus block (20 ml of ropivacaine 0.75%) was performed (n = 28). Then, depending on the individual sonoanatomy, 5 ml of prilocaine 1% was injected into the carotid sheath (group 1: no perivascular infiltration, n = 14, group 2: perivascular infiltration, n = 14). The third step was subplatysmal injection of 5 ml of prilocaine 1% between the medial edge of the sternocleidomastoid muscle and the submandibular gland (n = 28). The investigated parameters included the need for supplementation and block-related side effects. Results: The requirement for supplemental local anesthetic infiltration in the skin incision area was minimal at mean (M) 1.1 ml (standard deviation (SD) ±2.4 ml). Perivascular infiltration in group 2 significantly decreased the total amount of local anesthetic supplemented: group 1 M = 4.2 ml (SD = ±3.1 ml), group 2 M = 1.7 ml (SD = ±2.0 ml) (p = 0.018). The incidence of block-related side effects was not significantly different between the two groups. Conclusion: This study presents an ultrasound-guided subplatysmal block of the superficial ansa cervicalis for the first time, with the aim of optimizing anesthesia quality during surgical interventions in the carotid triangle.

Omohyoid muscle present in cervical region is of particular importance to anatomists as it defines anteriorly the carotid triangle and divides the posterior cervical triangle. It has superior and inferior bellies and an intermediate common tendon. Like sternohyoid, sternothyroid and thyrohyoid muscles, omohyoid is also an infrahyoid muscle, but it differs from them in its course. The infrahyoid muscles are formed from a muscle primordium occurring in the anterior cervical area. Anderson (Anderson, 1881) theorized that the superior belly of the omohyoid muscle is a true infrahyoid muscle, whereas the inferior belly most likely shares a common embryology with the subclavius muscle. In the present study, during routine dissection in the neck region of an adult male cadaver of 50 years age, an anomalous origin of inferior belly of omohyoid with absence of intermediate tendon was observed bilaterally. It was arising from clavicle on both sides. Both the muscle bellies were measured from the lateral end of fascial sling. The inferior belly of omohyoid extending from the lateral margin of sling to clavicular surface was measured 3.3cm in length on left side and 3.6cm on right side. The omohyoid is important in neck dissections because it is considered as an ideal landmark for level III and IV lymph node metastases. Knowledge of variations of this muscle is very important for surgeries in neck region because of its close relation to the internal jugular vein and brachial plexus. Its crucial relationship to vascular structures in the neck makes it an important landmark during neck surgeries.

Although penetrating neck trauma (PNT) is uncommon, it is associated with the significant morbidity and mortality. The management of PNT has changed significantly over the past 50 years. A radiological assessment now is a vital part of the management with a traditional surgical exploration. A 22 years old male was assaulted by a screwdriver and sustained multiple penetrating neck injuries. A contrast CT scan revealed a focal pseudoaneurysm in the left common carotid artery bulb. There was no active bleeding or any other vascular injuries and the patient remained haemodynamically stable. In view of these findings, he was initially managed conservatively without an open surgical exploration. However, the patient was noted to have an acute drop in his hemoglobin count overnight post injury and the catheter directed angiography showed active bleeding from the pseudoaneurysm. Surgical exploration 40 hours following the initial injury revealed a penetrating injury through both arterial walls of the left carotid bulb which was repaired with a great saphenous vein patch. A percutaneous drain was inserted in the carotid triangle and a course of intravenous antibiotics for five days was commenced. The patient recovered well with no complications and remained asymptomatic at five months followup. Keywords: Penetrating neck trauma, Management penetrating neck trauma, Investigation penetrating neck trauma, Assessment penetrating neck trauma

Background Microvascular anastomosis is an essential procedure in neurosurgery, but the opportunity to perform the surgery has gradually decreased for neurosurgeons. Therefore, training is necessary for obtaining and maintaining the skills required for the procedure. We describe the detailed anatomy of cervical and femoral regions in rats and discuss the advantages for practicing microvascular anastomosis. Methods Cervical regions of Sprague-Dawley rats were dissected under intraperitoneal anesthesia. The step-by-step anatomic description was documented using a high-resolution charge-coupled device image sensor and recording systems. Using this model, temporal occlusion time and patency were measured, and these measures were compared between the trainee and trainer groups. The number of times the training needs to be completed to attain competency in the bypass procedure was estimated. Results After exposing the carotid triangle, a half-ring was created by end-to-side anastomosis. Anastomosis was performed at the common carotid artery using the contralateral side of the carotid artery as a graft. The cutoff value for the temporal occlusion time was 79.3 minutes in the receiver operating characteristic curve based on a target temporal occlusion time for beginners determined during the training. Conclusions Using a living animal model, a trainee has the opportunity to learn not only anastomotic techniques but also hemostatic control as well as overcoming mental strain during surgery. Living animal models are important in training because the fidelity of a living animal model is superior to nonliving models. Applying training using a half-ring model contributes to safe and efficient surgery.

The infrahyoid muscles (omohyoid, sternohyoid, sternothyroid and thyrohyoid) are innervated by Ansa Cervicalis (AC) and are involved in movement of hyoid bone, thyroid cartilage during vocalisation and swallowing. Though variations in the formation and looping pattern of AC are reported in the literature, here we present a rare branching pattern of AC. During routine undergraduate dissection class, we have come across a rare variant of AC which has clinical significance. On the left side of the neck a common trunk was found to be arising from the loop of AC which trifurcated to supply inferior belly of omohyoid, sternohyoid and sternothyroid. This trunk was also providing a branch to sternocleidomastoid. Surgeons should keep such variation in mind while operating in the carotid region. If accidently during surgery or stab wound in the neck, this common trunk is cut, the function of inferior belly of omohyoid, sternohyoid and sternothyroid will be compromised leading to difficulty in deglutition and voice production. In unilateral vocal cord paralysis, artificially created anastomosis between AC and recurrent laryngeal nerve gives excellent to normal result in affected vocal cord. In thyroid surgery, recurrent laryngeal nerve is injured leading to vocal fold paralysis. To restore the nerve supply to the larynx in such cases neurorrhaphy (end to end anastomosis) between AC and recurrent laryngeal nerve is the choice of treatment.

Background: The anatomical structural Scenario of the largest Salivary glands, the parotid glands taken for study because of its clinical interventions like parotid abscesses, Sailoliths, growths may effect the intervening neurovascular bundle which passes through the substance of the parotid gland, and also its affiliations towards the scrotum in mumps. The swellings of the parotid glands cause compression on facial nerve. The Injury to the facial nerve during surgical procedures which may produces face muscles paralysis. The parotidectomy for benign and malignant growths warrants the surgeons for facial nerve injury. Methods: The study includes 50 parotid glands in dead fetuses; 20 parotid glands in adult cadavers of formalin fixed specimens. The glands are exposed according to incisions of Cunningham manual. The extents noted, capsule removed. Measurements taken, shapes observed and tabulated. Results: Variations observed and noted for the accessory lobes. The adult parotid glands are Pyramidal shaped (10 out of 10 glands). The foetal glands are 60% are Pyramidal (30 out of 50 glands), 40% are rounded shape (20 out of 50 glands). The apex extension to the carotid triangle is 20% in adult cadavers (2 out of 10 glands); 8% in foctuses (4 out of 50 glands). According to the measurements the length is 2 times more than the width of the gland in pyramidal shaped; the length and width are nearly equal in rounded shaped glands. The accessory parotid glands present in 20% of adult glands, 12% of foetal glands. Conclusions: According to the present Study major number glands are Pyramidal shaped in foctoses than rounded shape. All the adult glands are Pyramidal shaped glands. Accessory lobes present both adult & foetal specimens.

Background/Aim: External carotid artery (ECA) shows a variable branching pattern of its stemming vessels. The aim of this study was to investigate the variations in the origin of the three primary anterior branches of the ECA: superior thyroid artery (STA), lingual artery (LA), and facial artery (FA). Methods: The branching pattern of the ECA was studied on 15 Thiel embalmed cadavers of Scottish population (7 males and 8 females). The carotid triangle was dissected bilaterally to uncover the common carotid artery (CCA), internal carotid artery and ECA. The level of carotid artery bifurcation (CB) was located. Variation of the branching patterns of the ECA was assessed. Moreover, the distances between the origin sites of these vessels and the site of the CB were measured. Results: The STA was found to arise more frequently from the ECA (60%) than from the CCA (40%), with no differences in distribution between sexes or sides. Regarding the assessment of the branching patterns of the ECA, the specimens where the STA, LA, and FA emerged as individual branches were 90% of cases, linguofacial trunk cases were 6.7%, and thyrolinguofacial trunk cases were 3.3%. The distances from the vessel origin site to the CB were found to be 8.11 ± 2.77 mm, 19.38 ± 8.85 mm, and 27.95 ± 10.15 mm, for the STA, LA, and FA, respectively. Conclusions: The current findings have confirmed that the ECA branching pattern is highly variable in Thiel embalmed cadavers of Scottish population. Therefore, considering some radiological imaging before conducting any invasive procedure in the neck region could be vital to prevent iatrogenic injuries.

The internal jugular vein (IJV) is an important vascular structure for oncologists and radiologists and is also a frequently used central venous route. The varia­tions in the pattern of its course, and knowledge of its variations, are important. During the anatomical dissection of a 70-year-old male cadaver, fenestration involving a short segment (2.5 cm) of the right IJV in the superior part of the carotid triangle and a large dilatation (phlebectasia) of the IJV, involving its nonfenestrated segment were found — a case that has not previously been reported. The aetiology and clinical implications of the concurrent anomalies are described. Clinicians and surgeons performing neck vascular or reconstru­ctive surgery should be made aware of both IJV variations in order to prevent inadvertent injury and avoid invasive investigations and inappropriate treatment.

Ectopic cervical thymoma is an extremely rare tumor thought to arise from ectopic thymic tissue caused by the aberrant migration of the embryonic thymus. We present the case of a 44-year-old woman with an ectopic cervical thymoma located in the carotid triangle. A computed tomography (CT) scan detected a mass in her right carotid triangle. On an unenhanced scan, the tumor showed homogeneous isodensity compared with muscles, and neither fat nor calcification was detected. A contrast-enhanced CT image obtained during the arterial phase showed intratumoral septa, while an image obtained during the parenchymal phase showed cystic changes within the mass. The patient underwent a surgical resection. A histological study enabled a diagnosis of type AB thymoma in which foci with the features of type A thymoma are admixed with foci rich in lymphocytes. This subtype is a benign tumor with a good prognosis. Ectopic cervical thymoma should be included in the differential diagnosis of solid masses located in the carotid triangle when the CT findings are typical of a thymoma.

Facial artery plays a key role in blood supply of the face. Facial artery one of the anterior branches of the external carotid artery originates within the carotid triangle. Variation in the origin of the facial artery was observed on two sides out of 60 sides in 30 cadavers. Facial artery was observed originating at the level just below the maxillary artery within the parotid gland. Facial artery may originate as linguo-facial trunk or thyro-linguo-facial trunk. Other developmental variations have also been described in the literature like, agenesis of facial artery, enlarged facial artery, hypoplastic facial artery. Variability in situation may complicate the surgery. Therefore maxillofacial surgeon, plastic surgeons and head & neck surgeon should be aware of such variation.

Introduction Thyroidectomy and parathyroidectomy, can damage recurrent laryngeal nerves, we propose a new method for the stimulation of the vagus, not invasive, that allows also to differentiate right and left RLN. Methods In a total of 145 patients undergoing thyroidectomy and parathyroidectom, two subdermal needle electrodes were placed, the cathode on the angle jaw, and the anode on mastoid, bilaterally, reaching the carotid triangle in the upper neck, so we can stimulate vagus nerve without dissection. Using single stimulus, 0.2 ms of duration, intensities from 15 to 40 mA, an EMG response is obtained in the electrode placed in the endotracheal tube, latency 9–11 ms in right side and 10–13 ms in left side, reproducible, and without variations during surgery. Results We observed latency variations, when a sustained increase of EMG activity was recorded in the laryngeal electrode, while the surgeon was nearby RLN, and also bimodal response in those cases in which LRN division was observed during the dissection.In all them the unilateral LRN stimulation was seen. We also observed the presence of a peripheral silent period confirming the correct stimulation. Provided that we obtain the unilateral stimulation of the nerve, with minimal contraction of cervical musculature and practically not stimulation of the spinal nerve, this not disrupt the surgeon who does not need to stop to value integrity of the recurrent nerve. Conclusion This method, minimally invasive, always accessibly, that allows to value RLN of unilateral form, contributing major control in the monitoring of the nerves, without in none of 145 cases (290 RLN), side effects have been observed. A previous report has been made with transcutaneous stimulation of the vagus nerve, but in our experience, more intensity is needed, and spinal nerve is commonly stimulated, disturbing the surgeon, and it use is more limited.

Though the variations in the carotid arteries and their branches are common in the carotid triangle, it is important for the clinicians, surgeons and the radiologists to be aware of all possible variations of these arteries. A case of abnormal origin of 2 important arteries encountered during routine dissection of carotid triangle of the neck is reported. The superior thyroid artery that normally originates form the external carotid was seen to originate from the common carotid artery and the superior laryngeal artery was arising from the external carotid artery instead of the superior thyroid artery. Further, a detailed literature review was done and the surgical, radiological and clinical importance of the case was discussed.

DOI: 10.4328/JCAM.586 Received: 17.01.2011 Accepted: 02.03.2011 Printed: 01.05.2016 J Clin Anal Med 2016;7(3): 402-4 Corresponding Author: Guclu Kaan Beriat, Ufuk Universitesi Tip Fakultesi Dr. Ridvan Ege Hastanesi Kulak Burun Bogaz Anabilimdali, Balgat, 06520, Ankara, Turkiye. T.: +90 3122044175 F.: +90 3122847786 E-Mail: beriat4@gmail.com Ozet Ektopik tiroid dokusu tiroid dokusunun anormal migrasyonuyla olusan nadir gorulen bir tiroid patolojisidir. Yaklasik olarak 100,000-300,000 dogumda bir gorulur ve genellikle asemptomatiktir. Tiroid doku hiperplazisine bagli olarak, asemptomatik ektopik tiroid dokusu buyuyerek boyun kitlesi seklinde semptomatik hale gelebilir. Trakea onundeki normal lokalizasyonu disinda tiroid bezi, dil koku ile trakea arasinda genellikle orta hatta herhangi bir seviyede gorulebilir. 71 yasinda erkek hasta, boyun sag tarafinda, sag karotid ucgende 5x4x3 cm boyutlarinda kitle ile kulak burun bogaz poliklinigimize basvurdu. Yapilan ince igne aspirasyon biyopsisi sonucu tiroid dokusu olarak rapor edildi ve takiben kitle genel anestezi altinda eksize edildi. Yapilan patolojik degerlendirmesi sonucunda kitlenin atipik olarak yerlesim gosteren ektopik yerlesimli tiroid nodulu oldugu anlasildi. Hastanin yapilan bir yillik takibinde herhangi bir komplikasyonla karsilasilmadi.

The anterior triangle of the neck is bounded by the anterior border of the sternomastoid muscle, the lower edge of the mandible, and the midline. In clinical practice the structures deep to the sternocleidomastoid (SCM) muscle are considered to be inside the anterior triangle. The anterior triangle consists of four triangles, namely, digastric (submandibular) triangle, carotid triangle, muscular triangle, and submental triangle. The midline of the neck extends from the “symphysis menti” above to the “suprasternal notch” below (Fig. 9.1). The posterior triangle of the neck is bounded by the posterior border of the sternomastoid muscle, the anterior edge of the trapezius muscle, and the clavicle. The posterior triangle consists of two triangles, occipital triangle and subclavian (supraclavicular) triangle (Fig. 9.1) [1, 2].

Chondromas of the larynx are rare neoplasms; only a few examples of cartilaginous tumors affecting hyoid bone have been reported. A 33-year-old woman presented with a neck mass on the left carotid triangle. The patient's computed tomography and magnetic resonance imaging revealed a heterogenous mass, which seemed to originate from the left greater cornu of hyoid. The mass was excised using a transcervical approach with left greater cornu of hyoid bone. The pathologic diagnosis was chondroma of hyoid. Expert radiologic and pathologic review is mandatory in cartilaginous neoplasms of the larynx. Cartilaginous neoplasms of the hyoid should be included in the differential diagnosis of neck masses at the carotid triangle.

Background The carotid bifurcation can host a variety of tumors requiring complex surgical management. Treatment requires resection and, in some cases, vascular reconstruction that may compromise the cerebral circulation. The most frequent lesion at this location is the carotid body tumor (CBT). CBT are classified according to Shamblin in 3 types depending on the degree of carotid vessels encasement. Our main objective was to report our clinical experience managing carotid bifurcation tumors throughout the last 30 years. Methods Between 1984 and 2014, we treated 30 patients with 32 carotid bifurcation tumors. There were 21 women and 9 men (2.3:1), with a mean age of 45.5 years (18–75). The most frequent presentation was an asymptomatic neck swelling or palpable mass localized at the carotid triangle (86.7%). Results Thirty of 32 tumors were resected. Since 1994, computed tomography scan has been the most frequently used diagnostic imaging tool (80%), followed by magnetic resonance imaging. Angiography was used mainly during the first 10 years of the study period. Mean size of the tumor was 44.6 mm (20–73 mm). Nineteen (63%) were classified as Shamblin II and 6 (20%) as Shamblin's III. All specimens were analyzed by a pathologist; 28 tumors (93%) were confirmed as paragangliomas, 2 (7%) were diagnosed as schwannomas. Two patients underwent preoperative embolization of the CBT; 5 patients (17%) required simultaneous carotid revascularization, all of them Shamblin III. Mean hospitalization time was 4.5 days (1–35 days). Transient extracranial nerve deficit was observed in 7 patients (23.3%). Three patients (Shamblin III) required red blood cells transfusion. One patient (Shamblin III) underwent a planned en bloc excision of the vagus nerve. There was no perioperative mortality or procedure-related stroke. No malignancy or tumor recurrence were observed during follow-up. Conclusions CBTs can be diagnosed on clinical grounds requiring vascular imaging confirmation. These infrequent lesions are generally benign. Early surgical removal by surgeons with vascular expertise avoids permanent neurologic and or vascular complications.

Superficial head and neck vessels are increasingly used in surgical procedures and are especially important in facial transplantation surgeries. We report a variant course of the submental vein observed during a dissection of a 79-year-old-male embalmed cadaver: a left submental vein running caudally across the intermediate tendon of the digastric muscle, separating from the course of the submental artery and emptying directly into the common facial vein in the carotid triangle. Such course may complicate submental island flap harvesting, as well as the graft manipulations and reattachment, since the vein could be damaged during the conventional procedure. This report therefore extends current knowledge of the variations of the vascular anatomy of the head and neck.

Knowledge of the variations of the arteries in the carotid triangle is important because its existence can have significant impact on treatment success, especially during surgical or radiological intervention in the region. During routine students’ dissection of an adult male cadaver, as part of a functional human anatomy course, a rare anatomic variant was observed in the carotid triangle on the right side of the neck. The external carotid artery (ECA) and its anterior branches were located lateral to the internal carotid artery (ICA). In addition, the lingual and facial arteries arose in a common linguofacial trunk, which in this configuration coursed medially, crossing and partially obscuring the ICA. Both the hypoglossal and internal laryngeal nerves were at a risk of injury since they lay directly over the linguofacial trunk and the ICA. This is the first case report of a linguofacial trunk arising from a lateral ECA. The transposition of the ECA and ICA and presence of a linguofacial trunk could have profound surgical implications including potentially limiting access to the ICA during carotid endarterectomy. It is also expected to cause difficulties for catheter insertion. In addition, the risk of bleeding during pharyngeal surgery is increased in cases in which the ICA is medially displaced due to its anomalous course.

Variations in the vascular anatomy of the carotid triangle have been reported in current scientific literature. The carotid arteries, being the major feeding arteries of the head and neck deserve special importance and protection from iatrogenic injury during radiological evaluations and surgical interventions. The present study was carried out over a period of 4 years from 2012–2016 to assess the variant anatomy of external carotid artery. The external carotid artery and its branches were dissected bilaterally in 40 formalin embalmed cadavers. The external carotid artery was traced from its origin to termination and variations in the branching pattern as well as the level of the carotid bifurcation were observed and analysed. A higher carotid bifurcation was observed in 25% cases. The linguofacial trunk was the commonest variation noted in the branching pattern seen in 20% cases. A single case of unilateral thyrolinguofacial trunk was also observed. The external carotid artery gave rise to accessory branches in 7.5% cases namely the superior laryngeal, accessory ascending pharyngeal and masseteric branches. A slender branch to the internal jugular vein was also observed in one case. These findings may provide further insight into the understanding of the vascular anatomy of the carotid triangle to the curious student, the discerning radiologist and the vigilant surgeon to avert complications and help improve overall treatment outcome.

Objective:Variant anatomy of the hypoglossal nerve is very rare. We report an unusual intra-operative finding of an aberrant branch of the hypoglossal nerve, encountered during a facial reanimation procedure.Case report:A 50-year-old man was referred to the head and neck surgery department by the neurosurgeons for hypoglossal-facial nerve anastomosis to treat his facial paralysis, which had occurred following the removal of an intracranial neoplasm. During surgery, we identified an aberrant branch of the hypoglossal nerve, which took a more ventral and superior course in the carotid triangle, prior to entering the base of the tongue. Following further dissection, we found the main trunk of the ‘true’ hypoglossal nerve. Several interconnecting strands were seen in the proximal aspect of both the aberrant branch and the main trunk of the hypoglossal nerve. These interconnecting fibres appeared to have tethered the main trunk into an abnormal anatomical position.Conclusion:As far as we can ascertain, this is the first report of an aberrant branch of the hypoglossal nerve. Although this variant would appear to be extremely rare, surgeons must consider all variations of this nerve during head and neck procedures, in order to minimise iatrogenic complications.

Over past few years our group has been working on the development of a low-cost device, ARTSENS, for measurement of local arterial stiffness (AS) of the common carotid artery (CCA). This uses a single element ultrasound transducer to obtain A-mode frames from the CCA. It is designed to be fully automatic in its operation such that, a general medical practitioner can use the device without any prior knowledge of ultrasound modality. Placement of the probe over CCA and identification of echo positions corresponding to its two walls are critical steps in the process of measurement of AS. We had reported an algorithm to locate the CCA walls based on their characteristic motion. Unfortunately, in supine position, the internal jugular vein (IJV) expands in the carotid triangle and pulsates in a manner that confounds the existing algorithm and leads to wrong measurements of the AS. Jugular venous pulse (JVP), on its own right, is a very important physiological signal for diagnosis of morbidities of the right side of the heart and there is a lack of noninvasive methods for its accurate estimation. We integrated an ECG device to the existing hardware of ARTSENS and developed a method based on physiology of the vessels, which now enable us to segregate the CCA pulse (CCP) and the JVP. False identification rate is less than 4%. To retain the capabilities of ARTSENS to operate without ECG, we designed another method where the classification can be achieved without an ECG, albeit errors are a bit higher. These improvements enable ARTSENS to perform automatic measurement of AS even in the supine position and make it a unique and handy tool to perform JVP analysis.

We report the case of a liposarcoma arising in the parapharyngeal space. A 15-year-old boy who had complained of a tumor in the right submandibular region and swelling on the right lateral pharyngeal wall for one month was referred to the University of Tsukuba Hospital for further evaluation. A large tumor was recognized on CT and MRI, extending from the carotid triangle to the skull base in the right parapharyngeal space.The tumor was completely removed along with several cervical lymph nodes, and the pathological diagnosis was a “well-differentiated liposarcoma without metastasis to the cervical lymph nodes”. Radiation therapy was performed postoperatively with a dosage of 65 Gy. The postoperative course was uneventful, and there has been no sign of recurrence or metastasis over a 3 year follow-up period.Liposarcomas of the head and neck are commonly observed in males 40 to 60 years of age, and their occurence in children is extremely rare.In a review of the available literature, this is only the second case of a parapharyngeal liposarcoma in a child reported in English or Japanese literature thus far.

Inflammatory carotid pseudotumor is a rare differential of a unilateral neck swelling in the carotid triangle. A 48-year-old man presented with a firm non-tender gradually progressive left neck swelling for five months. Computed tomography angiogram revealed a mass encasing the common carotid. Patient underwent excision; histopathology was reported as inflammatory pseudotumor. Patient had a recurrence after eight months. Steroids were prescribed with which the swelling resolved, patient remained recurrence free at two-year follow-up.

A 53-year-old female complained of a growth in the left side of the neck. A tumor was found at the carotid triangle. It was elastic soft and measured approximately 3.0×3.2cm in size. Ultrasound scan confirmed the mass, which was well demarcated, solid, and with a complex echotexture. CT scans revealed that the tumor was located inside the sternocleidomastoid muscle and showed partly high-density-area suggestive of calcification.The tumor was removed en bloc and showed no connection to the thyroid. The macroscopic appearance more closely resembled thyroid tissue than cervical lymph node. Pathohistologically, it was normal thyroid tissue with thyroid follicles of varying sizes. There was no evidence of malignancy.

We report on a case of an emergency free flap cover of a pharyngeal defect which was made necessary by aggressive digestive salivatory and radiation effects 3 weeks after neck-dissection and laser ablation of an epidermoid left tonsil carcinoma. Life threatening intraoral bleeding resulted from the erosion of branches of the external carotid artery. After management of the bleeding, massive blood transfusions and restoration of the patient's general condition, a sandwich patch cover of the transmural pharyngeal defect was achieved using a microvascular lateral arm flap. This aimed at preventing further digestive effects and bacterial colonisation of the neurovascular structures at the carotid triangle. Unfortunately, due to external mechanical forces, the flap became avascular and thus necrotic at the eighth postoperative day; however, until the successful replacement by a myocutaneous latissimus dorsi flap it remained water-tight and fulfilled its sealing task.

Superior cervical ganglionectomy (SCGx) is a valuable microsurgical model to study the role of the sympathetic nervous system in a vast array of physiological and pathological processes, including homeostatic regulation, circadian biology and the dynamics of neuronal dysfunction and recovery after injury. Despite having several experimental applications in the rat, a thorough description of a standardized procedure has never been published. Here, we provide a brief review of the principal features and experimental uses of the SCGx, the surgical anatomy of the neck and sympathetic cervical chain, and a step-by-step description of how to consistently remove the superior cervical ganglia through the omohyoid muscle or the carotid triangle. Furthermore, we suggest procedures and precautions to be taken during and after surgery to optimize results and describe tools to validate surgical success. We expect that the following standardized and optimized protocol will allow researchers to organize knowledge into a cohesive framework in those areas where the SCGx is applied.

Background The lower cranial nerves must be identified to avoid iatrogenic injury during skull base and high cervical approaches. Prompt recognition of these structures using basic landmarks could reduce surgical time and morbidity. Methods The anterior triangle of the neck was dissected in 30 cadaveric head sides. The most superficial segments of the glossopharyngeal, vagus and its superior laryngeal nerves, accessory, and hypoglossal nerves were exposed and designated into smaller anatomic triangles. The midpoint of each nerve segment inside the triangles was correlated to the angle of the mandible (AM), mastoid tip (MT), and bifurcation of the common carotid artery. Results A triangle bounded by the styloglossus muscle, external carotid artery, and facial artery housed the glossopharyngeal nerve. This nerve segment was 0.06 ± 0.71 cm posterior to the AM and 2.50 ± 0.59 cm inferior to the MT. The vagus nerve ran inside the carotid sheath posterior to internal carotid artery and common carotid artery bifurcation in 48.3% of specimens. A triangle formed by the posterior belly of digastric muscle, sternocleidomastoid muscle, and internal jugular vein housed the accessory nerve, 1.90 ± 0.60 cm posterior to the AM and 2.30 ± 0.57 cm inferior to the MT. A triangle outlined by the posterior belly of digastric muscle, internal jugular vein, and common facial vein housed the hypoglossal nerve, which was 0.82 ± 0.84 cm posterior to the AM and 3.64 ± 0.70 cm inferior to the MT. Conclusions Comprehensible landmarks can be defined to help expose the lower cranial nerves to avoid injury to this complex region.

Introduction: clinical examination and surgical procedures require the knowledge of anatomical peculiarities of a complex area such as neck, especially if the anomalies in develoment of vascular system may occur. Aim: to investigate the mutual relation of the initial parts of the internal carotid artery and the external carotid artery, as well as the height of crossing of these blood vessels. Patients and methods: we evaluated 50 patients referred to diagnostic center of the PZU „Medicom“ Zenica, by using of magnetic resonance imaging (MRI) of the neck. Results: External carotid artery is placed medially and goes to the frontal side of the internal carotid artery in 90% cases. In 7% of cases the right internal carotid artery is placed laterall from the internal carotid artery. Divergent position, where the internal carotid artery (medially) and the external carotid artery go away from each other, was found in 1% of cases. We also found that the internal carotid artery and external carotid artery cross approximately 3.04 cm above the bifurcation (at right 3.05 cm and at left 3.12 cm) and the height of the crossing varies from 1.3 cm to 4.2 cm (at right 1.3 cm to 4.2 cm, and at left 1.5 cm to 4.1 cm). The height of crossing is symmetric in 18% of cases. Reversal of the position of the external and internal carotid arteries was found in 7% cases. Conclusion: The possibility of an inversed disposition of the internal and external carotid arteries must be held in mind when performing arterial ligatures in the carotid triangle, to avoid damage to the internal carotid artery or haemorrhagic accidents.

During dissection of the carotid triangle, a carotid trifurcation was encountered. The left common carotid artery gave off three terminal branches: external carotid, internal carotid, and occipital arteries. The level of trifurcation was 35 mm above the superior margin of the thyroid cartilage. Further, the superior thyroid artery arose from the common carotid artery instead of the external carotid. Herein, we describe the detailed anatomical features of the variant branching pattern of the left common carotid artery and its clinical implications. Clin. Anat. 14:58–61, 2001. © 2001 Wiley-Liss, Inc.

Superficial cervical region, punctum nervosum median cervical region carotid triangle thyroid region lateral cervical region submandibular triangle parotid-masseter region lateral facial region infratemporal fossa approach to the middle meningeal artery orbit and temporal region orbital region occipital region and posterior cervical region, suboccipital puncture suprascapular region dorsum of the thorax vertebrolumbar region, lumbar puncture lumbar region pectoral region female breast thoracic cavity posterior mediatinum pericardium heart and coronary arteries infraclavicular region axilla, axillary fossa upper arm anterior cubital region anterior antebrachial region anterior carpal region hand, palm, palmar aponeurosis hand, digital tendon sheaths posterior antebrachial region hand, dorsum of the hand shoulder joint, puncture sites elbow joint, puncture sites, puncture sites joints of the hand, dorsal and volar aspects, mechanics of the wrist, puncture sites.

During educational dissections a rare anatomic variant was encountered at the level of the right carotid triangle of a human adult male specimen. The variant was unilateral. On that side the common carotid artery bifurcated slightly above the level of the upper border of the thyroid cartilage, but the external carotid artery was posterolateral to the internal carotid artery and the anterior branches of the external carotid artery (superior thyroid, lingual and facial arteries) initially crossed over the internal carotid artery before continuing with a normal anatomical course. The possibility of an inversed disposition of the internal and external carotid arteries must be held in mind when performing arterial ligatures in the carotid triangle, to avoid damage to the internal carotid artery or haemorrhagic accidents.

During the routine dissection of the neck for the first MBBS students, we have found the abnormal branching of the external carotid artery in the carotid triangle. The external carotid artery is a terminal branch of the common carotid artery arises at the level of superior border of the thyroid cartilage in the carotid triangle. It supplies the structures of head and neck regions by its eight branches. The knowledge of variations is very important for the general, head & neck, ENT and oncosurgeons, to avoid unforeseen complication in the form of bleeding by injuring the abnormal arteries. It is also important for the vascular surgeons and radiologists while performing the procedures on the arteries.

The left superior laryngeal artery was observed arising from the external carotid artery instead of the superior thyroid artery in the cadaver of an approximately 70 year-old Asian man. In addition, on the same side, the superior thyroid artery arose from the common carotid artery 2 cm before the bifurcation instead of its usual origin from the external carotid artery. From the external carotid artery, the lingual and facial arteries arose from the common linguofacial trunk. The nerves in the carotid triangle were normal in course. No variations were observed on the right side carotid system. The multiple variations in this case have not been previously described. The embryogenesis of this combination of variations is not clear, but the anatomic consequences may have important clinical implications. As angiography has gained popularity in diagnostic approaches in recent years, it is essential to be aware of these variations so that they are not overlooked in differential diagnoses.

The aim of the present study was to test the safety and feasibility of the dorsal approach endoscopic thyroidectomy procedure in a prospective trial in humans, after the procedure had been developed ex vivo in human cadavers. A total of 28 patients were enrolled for 30 unilateral procedures of thyroidectomy. Two cases were staged bilateral procedures. Patients presenting with suspicious cold nodules, hot nodules, or goiters were operated on under general anaesthesia. Skin incision is carried out on the scalp, behind the ear. Deep to the sternocleidomastoid muscle, but respecting the superficial cervical fascia, the preparation goes past the carotid triangle to reach the thyroid below the straight neck muscles. Postoperatively the patients underwent neurological assessment, vocal cord examination, clinical control for hemorrhage, and determination of serum levels of Ca2+. Thirty unilateral procedures by the dorsal approach were carried out in 22 women and 6 men. There was 1 subtotal thyroidectomy and 29 total unilateral thyroidectomies with no conversions. There was one permanent recurrent laryngeal nerve (RLN) lesion and one postoperative hemorrhage. The size of the lobes removed ranged from 6 to 40 ml (mean: 18 ml). In four cases the specimen exceeded 38 ml. There was one multifocal papillary cancer requiring open surgical revision and lymphadenectomy. The other diagnoses were benign. All wounds healed by primary intention. Temporary impairment of cervical nerves was detected in six patients. It was possible to avoid access-related problems by improving the patient’s positioning on the operating table, omitting straight instruments, and respecting the superficial fascia before entering the carotid triangle. Hemithyroidectomy by the dorsal approach is feasible. It is a single surgeon, single port, gasless unilateral endoscopic technique with the option to go bilateral.

Interstitial tumor therapy guided by imaging techniques is minimally invasive and a promising surgical approach which will become clinically practical only when effective, simple, and safe modalities for tumor excision and control of tumor vascular supply are available. In a novel experiment utilizing a 1.5 T magnetic resonance (MR) scanner, the carotid artery of a New Zealand white rabbit was identified and then clamped using the Premium Surgicliptm 9.0' disposable automatic clip applier. The magnetic resonance imager equipped with an angiography package was used to locate vasculature in the carotid triangle of the rabbit via fast scan techniques. The artery was then clamped with titanium clips, and repeat magnetic resonance angiography (MRA) clearly demonstrated the cessation of blood flow within the chosen vessel. The experimental results are promising, since the angiography package not only provided the visualization of the arterial vessel, but was also used to guide an MR compatible surgical instrument to the vessel, with no artifact seen.© (1993) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

When the mouth is fully opened, the depth to which the needle is inserted need not be great in order to pass through the submandibular gland capsule, and insertion of the needle behind the second molar tooth would result in passage behind the posterior border of the mylohyoid muscle. The discussion indicates the relative ease with which fluid may penetrate the parapharyngeal space, particularly if pressure is used in injecting. Fluid diffusing into the region of the carotid triangle may have been responsible for the various symptoms, and anesthesia of the hypoglossal nerve, thyrohyoid nerve, internal and external laryngeal nerves, and carotid body possibly occurred. Anesthesia of the vagus is a remote possibility.

The cervical course of these vessels in the carotid triangle is shown (Fig. 2.1.1). Following skin incision, dissection of the subcutaneous tissue, platysma, and anterior cervical fascia, the internal jugular vein is usually exposed first at the front margin of the sternocleidomastoid muscle. Its caudal portion lies ventral and lateral to the common carotid artery and its cranial portion at the same level as the artery. The medial branches of the jugular vein vary greatly. The main branches are the common facial vein, usually found at the level of the carotid bifurcation, and the caudally terminating superior thyroid vein, but a common thyrolinguofacial trunk is also possible.

As stated earlier, we have chosen to present those topographic aspects of the vascular system that are of greatest importance for the surgeon, rather than a systematic anatomy with a division into arteries and veins. The veins that have been discussed, together with their corresponding regions, are: internal jugular vein, carotid triangle (p. 13); subclavian vein, sternocleidomastoid region (p. 13); axillary vein, axillary region (p. 19); inferior vena cava, renal veins, and variations, discussed in the section on the retroperitoneum (p. 19); iliac veins, femoral veins, saphenous vein junction and variations in the sections on pelvic and lower limb vessels (p. 22).