Triangles of the neck
The neck is divided by the
sternocleidomastoid muscles into:
anterior and posterior triangles.
Anterior triangle of the neck
 The anterior triangle is bounded laterally by the SCM
muscle, medially by the midline, and superiorly by the
The anterior triangle can be further divided into carotid
and submandibular triangles.
In the carotid triangle the carotid pulse may be felt.
In the anterior triangle the hyoid bone can be palpated.
On swallowing the hyoid bone can be felt to rise.
As the hyoid rises it pulls with it the thyroid cartilage
which forms the Adam's apple.
Posterior triangle of the neck
 The posterior triangle is bounded posteriorly by
the trapezius muscle, anteriorly by the SCM.
muscle and inferiorly by the clavicle.
 Much of the cervical nerve plexus emerges in the
posterior triangle.
 The spinal accessory nerve runs subcutaneously
across the posterior triangle from the posterior
border of SCM to the anterior border of trapezius.
It supplies both muscles
Triangles of the neck
 Anterior triangle of the neck
 thyroid isthmus
 Posterior triangle of the neck
 Spinal accessory nerve
 Brachial plexus
 Subclavian artery-third part
 External jugular vein
 Parotid gland
Triangles of the neck
 A. Anterior triangle
 muscular triangle--formed by the midline, superior belly of the omohyoid,
and SCM
 carotid triangle--formed by the superior belly of the omohyoid, SCM, and
posterior belly of the digastric
 submental triangle--formed by the anterior belly of the digastric, hyoid, and
 submandibular triangle--formed by the mandible, posterior belly of the
digastric, and anterior belly of the digastric
 B. Posterior triangle
 supraclavicular triangle--formed by the inferior belly of the omohyoid,
clavicle, and SCM
 occipital triangle--formed by inferior belly of the omohyoid, trapezius, and
Anterior triangle of the neck
 Above the thyroid cartilage, is the hyoid bone.
 Below the thyroid cartilage in the midline is the
cricoid cartilage.
The trachea continues on from the cricoid cartilage.
The cartilages of the trachea can be felt until it enters
the thorax behind the manubrium.
The trachea can be moved from side to side.
The thyroid gland lies on either side of the trachea
and crosses it anteriorly at about the second ring.
The thyroid is covered anteriorly by the thin strap
muscles and lies in part under the SCM. muscles.
Anterior triangle of the neck
Thyroid gland
Anterior aspect of the neck
• Body of the hyoid bone
• Thyrohyoid membrane
• Upper border of the thyroid cartilage
• Cricothyroid ligament
• Cricoid cartilage
• Cricotraheal ligament
• First ring of the trachea
• Isthmus of the thyroid gland
• Suprasternal notch
Posterior aspect of the neck
 External occipital protuberance
 Nuchal groove
 C7 spinal process
Carotid sheath
Carotid artery
Internal jugular vein
Vagus nerve
Deep cervical lymph nodes
Marked out by a line joining the sterno-clavicular joint
to a point midway between the tip of the mastoid
process and the angle of the mandible.
At the upper border of the thyroid cartilage, CCA
bifurcates into the internal and external branches.
The pulsations can be felt at this level.
Carotid sheath- common carotid artery, internal
jugular vein, vagus nerve with its superior
laryngeal branch
Common carotid artery: external carotid artery, internal carotid artery
Branches of ECA: superior thyroid artery , superior laryngeal artery,
lingual artery, facial artery.
Lumps in the neck
Lumps in the neck
1. Lymph nodes- lymphadenopathies:
 Infections
 Metastatic tumors
 Primary tumors
2. Tumors- cystic or solid
3. Thyroid gland- Goitre- diffuse or nodular
Case report
 Patient: An 8-year-old girl, Address: country side of
Chiang Mai province
 CC : Fever for 10 days and sore throat for 6 days
 History > 10 days , she had an acute onset of high-graded
fever. She took paracetamol but the fever and headache
> 6 days, she was seen by a doctor who gave a diagnosis of
acute tonsillitis (injected and enlarged tonsils, body
temperature 40 C,
 CBC: Hb 11.0 gm%, HCt 34%, WBC 4,600/, N 68%,
B 1%, L 29%, platelets 177,000/
Case report
 She was given intramuscular lincomycin 450 mg and oral
amoxycillin 250 mg 3 times a day. High intermittent fever
 > 2 days, she developed rashes over the trunk, arms, and
thighs. She also had various nonspecific symptoms,
including faintings, mild nausea, periumbilical abdominal
pain, diarrhea, mild sore throat, nonproductive cough, and
severe bitemporal headache.
 > On admission day, the fever persisted and her sore throat
got worse
Case report
 Past History:
The girl had history of cleft lip and cleft palate which were
repaired since she was 3 months old.
 Her immunization status was up to date.
 There was no family history of similar illness.
 She usually plays around her house where grass and tree
wildly grow on humid ground.
Physical examination
VS: T 39.5 C, pulse rate108/min, RR 24/minm,
BP=100/60 mmHg., BW 20 Kg
GA: looked sick, but fully concious
Skin: faint maculopapular rashes were observed
over arms and thighs .
An ulcer with black crust on erythematous base was
seen over her right shoulder region . Its size was
approximately 8.0 mm in diameter. The lesion was
not tender.
 Multiple enlarged lymph nodes were palpated as
 2 large: 1,3 and 1,2 cm. in diameter on right
supraclavicular triangle
 Multiple small lymph.nodes< diameter in chain
along both sides of posterior triangle
All nodes were soft, not-tender, movable and smooth
Case report
 ENT examination revealed enlarged tonsils grade III/IV
with hyperemia which extended on anterior tonsillar pillars
and soft palate were detected. There was no exudative
patch. Her pharynx was not injected. Her conjunctiva was
Chest: Heart sound: WNL, Lungs: no adventitious sound
Abdomen: palpable liver (4 cm below right costal margin,
span 13 cm.), spleen was not palpable
Maculopapular rash
A black crusted ulcer- right shoulder
Cervical lymphadenopathies
Enlarged tonsils with hyperemic soft palate
Case report
 Active Problem list:
1. Prolonged fever for 10 days
2. Nonspecific systemic complaints: faintings, nausea,
abdominal pain, diarrhea, sore throat, cough, headache,
poor appetite
3. Generalized maculopapular rash
4. Cervical and supraclavicular lymphadenopathy
5. Injected and enlarged tonsils with hyperemic soft palate
6. A black crusted ulcer at the right shoulder
7. Hepatomegaly
Case report
 Initial laboratory investigations:
CBC: Hb 9.2 g/dl, Hct 28 %, WBC=5,200/ (N
80%, L 20%), platelets 131,000/
Peripheral blood smear for malarial pigment:
Case report
 Since the provisional diagnosis of "scrub typhus" was made, the
therapeutic diagnosis was started with oral doxycycline 2.2 mg/kg/dose
given every 12 hrs (for the first 2 doses) .
The fever dramatically subsided.
Twelve hours later, she became more cheerful and her appetite
returned. Therefore, doxycycline (2.2 mg/kg/day div q 12 hrs) was
The hyperemic soft palate and tonsils subsequently faded off. The
tonsils were slightly decreased in size 36 hours after doxycycline.
The lymph nodes and liver remained palpable at the time of the
discharge from the hospital on day 3 of the treatment. Doxycycline was
continued for 14 days.
Temperature chart
Case report
 Follow-up: Seven days after the discharge (10 days
after doxycycline) she was followed up.
 She was afebrile and had no rash. The lesion
(eschar) moderately reduced in size.
 Her tonsils and lymph nodes became normal size
for age. Liver was just palpable below right costal
 Scrub typhus is a febrile illness caused by Orientia tsutsugamushi, an
obligate intracellular bacterium in the Rickettsiaceae family.
 The organism is transmitted during the bite of trombiculid mites (chigger).
Field rodents are the reservoir hosts. Scrub typhus is confined to a definite
geographic region. It extends from northern Japan and far eastern Russia in
the north, to northern Australia in the south, and to Pakistan and
Afghanistan in the west.
 In 2000, there were 3,914 cases (6.34 cases per 100,000 population) of scrub
typhus reported to the Thai Ministry of Public Health (MOPH).
 The true incidence is probably much higher since tests for anti-O.
tsutsugamushi antibody are available in only a few medical centers in
Case report
 Diagnosis and differential diagnosis of a patient with "eschar "
Although this case had no serologic verification, the course of illness,
systemic manifestations, a typical eschar, and therapeutic response led
to the diagnosis of scrub typhus without difficulty.
 Tularemia, spotted fever rickettsiosis, and anthrax can present with
eschars but by the epidemiology and clinical course they could be
excluded in this case.
 Eschar is a very useful sign in making the diagnosis.
 Eschar, if carefully searched, was seen in 25-75% of patients with scrub
Case report
 Where should we search for? "eschar"
 Eschar occurs as the result of mite (chigger) bite.
Since the chigger is small (<5 mm) and the bite is
neither painful nor itchy, the history of the bite
was not usually obtained.
 The mite lives in bushes.
Case report
 How can scrub typhus present with tonsillitis?
 After mite bite (inoculation) the rickettsiae multiply and
spread to the adjacent lymphoid structures.
 The lymph nodes from the neck/shoulder region drained
into nearly ipsilateral superficial cervical lymph node and
deep cervical lymph node. Then, there are communications
from intraoral structure (tonsil and nasopharynx), cervical
lymph nodes, to the the contralateral neck.
 Tonsillitis, cervical and supraclavicular lymphadenopathy
in this case, represented the regional lymphadenopathy in
scrub typhus
Case report
 Patient: A 9-year-old HIV-infected girl Address: Payoa province
(Northern Thailand)
CC: Pain at both eyes for 4 weeks. Fever for 3 weeks.
Present Illness: 4 weeks PTA, after coming back from swimming in a
river, she started having pain at her both eyes (more on the left side).
The pain later accompanied with tearing, yellowish discharge and
photophobia. The eye drop medicine from the local hospital could not
relief her eye pain.
3 weeks PTA, she developed moderate grade fever and mild dry cough.
Her eye pain persisted.
She lost her appetite and was admitted to a hospital where she received
ceftriaxone 70MKD, and ampicillin for 1 week without improvement.
Case report
 1 week PTA, all symptoms persisted and she
started having abdominal pain.
 Past medical history:
 At the age of 3 years she was diagnosed as
having HIV infection.
 Her mother has a history of pulmonary
tuberculosis and has been on treatment for 7-8
 She has not gained weight for 1 year.
Case report
 Physical examination:
 GA: febrile, thin and fatigue. BW=18 kg
 Vital signs: T: 40 celcius, RR: 36/min, PR: 122/min, BP:
110/72 mmHg
EYES; pale and injected conjuctivae, left corneal ulcer and
Oral cavity; whitish patches (thrush)
Ears; intact both tympanic membranes
Lymph nodes: Right supraclavicular lymphnode
enlagement: 2 cm in diameter, firm, not tender
Case report
 Heart: Tachycardia, no murmur
 Lungs: Medium creppitation both lungs
 Abdomen: Distension, generalized mild tender, liver 4 cm
below RCM,
 Extremities: no clubbing of fingers
 Skin: hypo- and hyperpigmentation scars at extremities.
 Neurological examination: no meningial sign, no
neurological deficit
Supraclavicular lymphnode
Corneal ulcer
Case report
Problem list:
 1. HIV-infected child with prolonged fever
 2. Corneal ulcers
Case report
Laboratory investigations:
CBC: Hb 6.1 g/dl, Hct 18%, WBC 3,600/mm3 (N=74%, L=22%,
M=16%) CD4 T-cell count: 4% (20 cells/mm3) Tuberculin skin
test : Negative
CXR: Cardiomegaly, generalized reticulo-nodular infiltration both lungs
suggesting miliary tuberculosis.
Echocardiogram: Generalized cardiac dilatation, particularly left size
was larger than right side. Mild depressed LV systolic function. Small
amount of pericardial effusion. Most likely, the lesions are caused by
tuberculous myopathy.
Cardiomegaly, miliary tuberculosis
Case report
 Diagnosis: HIV-infected child with miliary tuberculosis, and
herpes simplex keratitis
 Treatment: 1.
 Miliary tuberculosis : INH (15MKD), RF (15MKD), PZA (25 MKD), S(25
 Herpes simplex keratitis: Acyclovir ointment 5 times/day 3.
 Cardiac dysfunction: Douzabox (1 tb tid), Enalapril (0.125MKD),
Digoxin (6.25 microgramKD) 4.
 Anemia: Ferrous Fumarate Co (1.5 tb OD) 5.
Case report
 Course of illness:
After she received the anti-tuberculous drugs and
cefotaxime for 4 days, the fever subsided
Her abdominal pain decreased. She gained appetite. Her eye pain and
photophobia slowly recovered.
Her cardiac condition gradually improved.
The heart size was within normal limit.
The previous mediastinal (hilar) lymphadenopathy partially subsided.
Although each nodule of the "miliary" pattern was smaller in size, the
pulmonary infiltration persisted.
Temperature and pulse chart
Post=treatment CXR
Thyroglossal cyst
CT- thyroglossal cyst
Midline neck lump
Case report
 A 58-year-old man with a history of hypertension, type
2 diabetes mellitus, and hyperlipidemia presents to the
emergency department with a large, painless mass on
the anterior aspect of the neck.
 He reports that the mass developed over the past 3
days, preceded by a sore throat and mild subjective
fevers for several days
Case report
 He denies having any associated dysphagia,
hoarseness, drooling, or stridor.
 He denies having a history of neck or oropharyngeal
trauma, weight loss, night sweats, or cough.
 He has no history of tobacco use or alcohol abuse.
Case report
 On physical examination, the patient is a healthy-
appearing Asian man in no apparent distress. No
hoarseness is noted.
 The oropharynx has no notable lesions or apparent
mass effect.
 On the anterior aspect of the neck is a 2 X 3-cm,
smooth, soft, ovoid mass extending from the hyoid to
the cricoid cartilage
Case report
• The mass elevates when the patient swallows or
protrudes his tongue.
On direct visualization with flexible laryngoscopy,
the posterior part of the nasopharynx appears
normal. The airway is clear and patent, without
evidence of mass or external compression. The true
vocal cords appear normal.
Laboratory results, are within normal limits.
A CT scan of the neck is ordered.
What is the diagnosis?
Thyroglossal cyst
 Location- between the thyroid isthmus-hyoid bone
 Close to the midline
 Spherical and smooth
 Hard consistence- high tension within the cyst
 Fixed to the hyoid bone
 Moves upwards when the tongue is protruded
Thyroglossal cyst
 Cysts of the thyroglossal duct result from hypertrophy
of the remnants of the embryological thyroglossal duct
 Typically atrophies during the 10th week of
 The stimulus for the sudden expansion of a chronically
present tract is often an upper respiratory tract
 which results in lymphoid tissue enlargement that
occludes the tract and that results in cyst formation.
Thyroglossal cyst
 Patients with thyroglossal duct cysts usually present with
an asymptomatic, cystic midline mass in the upper part of
the neck, often after an upper respiratory tract infection.
The cyst may be slightly tender and occasionally results in
mild dysphagia.
The cysts may occur anywhere along the tract of the
thyroglossal duct from the foramen caecum of the tongue
to the thyroid gland.
The typical cyst moves up when the patient swallows or
protrudes the tongue because of the anatomic attachment
to the hyoid and larynx.
Treatment is surgical excision of the thyroglossal duct cyst.
Branchial cyst
 Congenital lesion- arising from epithelial remnants of
a branchial cleft ( pharyngeal groove)
 It may not distend and cause symptoms until adult life
 Painless swelling in the upper lateral part of the neck
 It lies behind the anterior edge of the upper third of
SCM. muscle and bulges forwards
 Pain is caused by infection
 It may fluctuate but cannot be reduced or compressed
Branchial cyst
A cyst in the posterior triangle of the neck
is extremely rare – case report
 A 23 year old female presented with a solitary
swelling in the left side of the neck of 6 months
 Initially the swelling was small, and gradually
increased to attain the size of an apple.
 There was no pain in the swelling.
Physical examination
 On examination an 8 cm x 7 cm swelling was
found in the left posterior triangle of the neck.
 It extended from the anterior border of the left
sternomastoid to the anterior border of the left
trapezius, anteroposteriorly and from the level of
the thyroid prominence superiorly to about 3 cm
medial to acromion process inferiorly.
 The smooth, well-defined swelling was fluctuant
and transluminant
Case report
 On operation a well-circumscribed
unilocular cyst was found without any
connecting tract or cord to the skin or the
 The cyst contained clear yellowish fluid.
 Microscopic examination of the cyst wall
revealed a focally preserved flattened
cuboidal epithelial lining.
Branchial cyst- anterior view
Branchial cyst- lateral view
Carotid body tumor
 Rare tumor, of the chemoreceptor tissue in the carotid
 Location- upper part of the anterior triangle, level with
the hyoid bone, beneath the ant. edge of SCM.
 Painless, slowing growing tumor
 The tumor pulsates
 Transient cerebral ischemia may be present
Carotid artery
Carotid bifurcation
Carotid body tumor
Carotid body tumor
Examination of the thyroid gland
 First confirm that the swelling in the neck is in the
throid gland- ask the pt. to swallow- the lump will
move up
 Look at the whole pt.- calm or agitated, thin or fat,
under-or over-clothed, moist or dry hands
 Palpate the pulse- tachy, bradicardic or irregular
 Look at the eyes:-lid retraction, exophtalmos,
Examination of the thyroid gland
 Palpate the neck from the front- nodule, trachea
 Palpate the neck from behind
 Look for laterocervical lymph nodes
 Enlargement of the thyroid gland
 Diffuse or nodular
 Sollitary nodule or multiple nodules
Site, shape, size, surface, tenderness, composition,
Nodular goitre
Nodular goitre
 Neck signs
 Eyes signs
 General signs
 Neck
 Eyes
 General
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