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The larynx • Nerve supply: Palpable components • Motorarecurrent laryngeal nerve 20 mg erectafil with visa, except for the cricothyroid • Hyoid bone generic erectafil 20 mg overnight delivery, level of C3. Below the vocal cords, the recurrent laryngeal nerve (which is therefore a Other components mixed nerve) which enters the larynx just behind the cricothyroid • Arytenoid cartilages: attached to upper border of the cricoid by syn- joint. If one of the recurrent laryngeal upper border of the cricoid and passes inside the thyroid to be attached nerves is divided, the cord lies in a position midway between adduction to the back of the thyroid and to the vocal processes of the arytenoids and abduction but this does not produce very severe voice changes (Fig. The upper border is thickened to form the vocal ligament because the uninjured cord can cross the midline to reach the para- which, with the mucous membrane that covers it, forms the vocal lysed cord. If both nerves are damaged but not • Cricothyroid joint: a small synovial joint between the inferior horn completely divided the cords are adducted since the abductors are of the thyroid cartilage and the cricoid, permitting a hinge-like move- more affected than the adductors (Semon’s law). The pharynx and larynx 139 63 The root of the neck Middle cervical ganglion Scalenus medius Vertebral artery Scalenus anterior Sympathetic trunk Phrenic nerve Inferior thyroid artery Upper trunk of brachial plexus Superficial cervical artery Vagus Suprascapular artery, nerve Subclavian artery Dorsal scapular artery Subclavian vein Carotid sheath Internal thoracic artery Inferior cervical ganglion Thoracic duct Fig. The curved arrow on the right side of the diagram indicates the course of the thoracic duct Scalenus posterior Sympathetic trunk Superior intercostal artery Attachment of scalenus medius 1st thoracic nerve Serratus anterior 8th cervical nerve (first digitation) Lower trunk of brachial plexus Scalene tubercle, Subclavian artery for attachment of Subclavian vein scalenus anterior Subclavius Costoclavicular ligament Fig. The subclavian artery and the Through this relatively confined space pass the trachea and oesopha- trunks of the brachial plexus are between the two muscles and the sub- gus, the carotid and subclavian arteries and the corresponding large clavian vein is in front of scalenus anterior. At the outer border of the 1st rib it becomes the axillary scalenus anterior before crossing the subclavian artery and entering the artery. The The veins middle cervical ganglion is close to the entry of the artery into the fora- • The subclavian vein: begins at the outer border of the 1st rib and lies men transversarium of C6 and the inferior cervical ganglion is near the in a shallow groove on the upper surface of the rib in front of scalenus neck of the 1st rib behind the origin of the vertebral artery. At the medial border of this muscle it is joined by the internal fused with the 1st thoracic ganglion to form the stellate ganglion. The internal jugular vein is enclosed in the carotid sheath, along with the common carotid artery The thoracic duct (Fig. The duct ascends out of the thorax between the ies but the inferior thyroid veins are solitary and run down from the trachea and oesophagus and arches laterally between the carotid sheath lower border of the thyroid gland, in front of the trachea, to reach the in front and the vertebral artery behind. The nerves • The upper, middle and lower trunks of the brachial plexus: emerge from between the scalenus anterior and medius and pass down The root of the neck 141 64 The oesophagus and trachea and the thyroid gland Thyrohyoid Superior thyroid artery Sternothyroid Cricothyroid Common carotid artery Inferior thyroid artery Inferior thyroid artery Right recurrent laryngeal nerve Inferior thyroid veins Left brachiocephalic vein Fig. A large part of the right lobe has been removed The oesophagus These infrahyoid muscles are all supplied by the ansa cervicalis (C1, The oesophagus begins at the level of the cricoid cartilage and runs 2 and 3). Their function is to fix the hyoid bone so that the suprahyoid down behind and slightly to the left of the trachea. Their main importance lies in their close laryngeal nerve is in the groove between the oesophagus and trachea relation to the thyroid gland. The thyroid gland The trachea The thyroid is an endocrine gland with an extremely rich blood supply The trachea begins at the level of the cricoid cartilage and ends by (Fig. Its isthmus lies across the 3rd, 4th and 5th rings of the tra- dividing into left and right bronchi at the level of the manubriosternal chea and the lobes lie on either side, reaching up as far as the ‘pocket’ joint. The trachea can be palpated in the midline just above the sup- under the attachment of sternothyroid to the thyroid cartilage. The upper enclosed in the thin pretracheal fascia and also has its own fibrous part of the trachea is crossed by the isthmus of the thyroid. When the gland is enlarged, the strap muscles are stretched bronchi and lungs develop from a groove in the floor of the embryonic tightly over it and the carotid sheath is displaced laterally. It divides into two branches which run down the posterior border and The infrahyoid (‘strap’) muscles along the upper border. It is thus possible to tie all four arteries during subtotal • Sternohyoid: is superficial to the other two and runs from the thyroidectomy and still leave an adequate blood supply to the manubrium to the lower border of the hyoid. They (thyroglossal duct) in the position of the future foramen caecum of the are about the size of a pea and are embedded in the back of the thyroid tongue. They develop from the third (inferior parathy- The stem of the outgrowth, the thyroglossal duct, normally disappears roid) and fourth (superior parathyroid) pharyngeal pouches of the although it may remain in part. The thymus also develops from the third pouch and may drag where along the course of the duct or thyroglossal cysts may appear. The oesophagus and trachea and the thyroid gland 143 65 The upper part of the neck and the submandibular region Hypoglossal nerve Internal jugular vein Internal carotid artery Occipital artery Glossopharyngeal nerve Spinal accessory nerve Superior laryngeal nerve Vagus nerve Hypoglossal nerve C2 Lingual artery Internal laryngeal nerve C3 External laryngeal nerve Superior ramus of ansa cervicalis Fig.

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