Platysma

The platysma is best described by the etymology of its name, derived from the Greek term for “flat plate”. It is a flat, broad muscle arising from the subcutaneous tissue of the upper parts of the thorax anterior to the clavicle. ^, From here, it ascends laterally before blending with and inserting to the superficial musculoaponeurotic system as it crosses the mandible and continues into the face. ^, The superficial facial muscles share a common embryologic origin from the second branchial arch, explaining their shared neurovascular supply. Thus, its embryological origin accounts for its innervation by the cervical branch of the facial nerve. ^{, ,} The submandibular branch of the facial artery and the suprascapular branch of the thyrocervical trunk account for the vascular supply to the muscle. When contracted, the platysmal fibers act to tense the skin of the neck and depress the lower lip and mandible. ^, All the structures discussed here within lie deep to the platysma.

Infrahyoid muscles

The strap or infrahyoid muscle group is composed of 4 paired muscles, and their anatomical relationships are best understood if divided into 2 coronal planes: superficial and deep. Deep to the platysma sits the superficial group, consisting of the sternohyoid (SH) and omohyoid (OMH) muscles, from medial to lateral ( Figure 1 A). The deep muscle group, also consisting of 2 muscles, is arranged in series rather than in parallel and includes superiorly located thyrohyoid (ThH) and inferiorly located sternothyroid (STh) muscles. Primarily, these muscles work to depress the hyoid bone and elevate or depress the larynx. ^, They receive innervation by the ansa cervicalis, with the exception of the thyrohyoid muscle, which is innervated by fibers of the first cervical spinal nerve travelling through the hypoglossal nerve. Branches of the superior and inferior thyroid arteries (STA and ITA, respectively) carry blood supply to all 4 strap muscles.

Anterior view of relevant structures in the central neck, progressively removing strap muscles from left to right. (A) The thyroid and its pyramidal lobe are shown deep to the strap muscles. The omohyoid (OMH) and sternohyoid muscles are shown in this layer. The relationship of the anterior jugular vein (AJV) to the strap muscles is shown, as it drains into the internal jugular vein (IJV). The jugulovenuos arch (JVA) is shown draining into the AJV. (B) Removal of the superficial strap musculature reveals the sternothyroid and thyrohyoid muscles. The superior thyroid artery (STA) is shown taking off from the external carotid artery (ECA). (C) Illustration showing the superior laryngeal artery (SLA), and the cricothyroid branch arising from the STA. The superior thyroid vein (STV) and middle thyroid vein (MTV) are shown draining into the IJV. The inferior thyroid veins (ITV) are shown, both of which drain into the left brachiocephalic vein (not shown).

The OMH is comprised of superior and inferior bellies joined by an intermediate tendon that is secured to the clavicle by a fascial sling. Its inferior belly originates from the superior border of the scapula, medial to the suprascapular notch. ^, From there, it travels anterosuperiorly until it reaches the intermediate tendon, a narrowing or tightening of the muscular fibers that allows the OMH to pass through the fascial sling. In turn, this sling tethers the OMH to the clavicle and facilitates hyoid bone depression. A study on 299 OMH dissections by Langsam et al. found that a constriction of the intermediate tendon was present in 46% of muscles. A change in trajectory occurs at the tendon lateral to the sternohyoid, as the superior belly of the OMH courses superomedially towards the junction between the greater cornu and the body of the hyoid on the bone’s posteroinferior surface. ^{, ,}

During deglutition, the OMH aids in depressing the hyoid bone, particularly when placing the tip of the tongue on the hard palate, and when the shoulder is abducted at a 90° angle. ^{, ,} Due to its relationship with the anterior wall of the internal jugular vein (IJV) and the thin adhesions formed by the pretracheal layer of the deep cervical fascia, contraction of the OMH may lead to changes in the caliber of the lumen of the IJV, potentially leading to changes in cerebrovascular hemodynamics. A pedicle arising from the infrahyoid artery (IhA), itself a branch of the STA, typically pierces the superior belly of the OMH approximately 2 cm inferior to its superior attachment, supplying the superior belly, though in some studies 2 branches may be found. ^, The vascular supply to the inferior belly of the OMH is less consistent and often excluded from cadaveric studies because of their limited usage in reconstructive surgery. Its main pedicle can arise from the ITA, the transverse cervical vessels, or directly from the subclavian artery. Prior to joining the inferior root and forming the ansa cervicalis proper, the superior root of the ansa cervicalis innervates the superior belly of the OMH, while its inferior belly is reached by fibers of the ansa itself distal to the anastomosis of the 2. ^,

At the level of the hyoid bone, the SH lies medial to the OMH. Inferiorly, it arises from the posterior aspect of the sternoclavicular joint capsule and clavicle via a long yet thin tendon at its base, located 5mm lateral and 1mm inferior to the superior manubrial articular cartilage. Here starts its uninterrupted vertical trajectory in the neck, culminating at its superior attachment to the inferior surface of the body of the hyoid bone by a 6 mm-wide tendon immediately medial to the OMH. ^, A branch from the ansa cervicalis arising distal to the formation of the loop innervates the SH approximately 3 cm above the sternal notch, while a vascular pedicle arising from the IhA supplies the muscle at the level of the inferior thyroid cartilage lamina. ^{, ,} At its inferior end, contributions from the glandular branches of the ITA are frequently seen entering the muscle. During jaw depression for speech, mastication, and swallowing, the SH primarily aids in depressing the hyoid bone.

Deep to the superficial muscle group lie the ThH and STh ( Figure 1 B). Deep and slightly medial to the inferior attachment of the SH sits the STh muscle, originating from the posterior surface of the manubrium and first costal cartilage. ^, From here, it follows a vertical path immediately deep to the sternohyoid but superficial to the thyroid gland and cricothyroid muscle prior to inserting into the superior and inferior thyroid tubercles and the tendinous arch connecting the 2. ^, This observation by Fischer and Tillmann, supported histologically by their study, contrasts with that of Sato et al. where an insertion into the oblique line of the thyroid cartilage is described. ^, However, the oblique line is a shallow ridge on the external surface of the thyroid cartilage that extends between tubercles, like the tendinous arch that overlies this landmark. Thus, an insertion to the oblique line or the overlying tubercula-arch complex is indistinguishable to the naked eye. Despite its controversial insertion, the relationship of the STh with the external branch of the recurrent laryngeal nerve (EBRLN) is consistent, with the nerve found deep to the STh insertion. Vascular supply of the STh muscle is variable, as muscular branches arise from branches of the STA, commonly the IhA, or from glandular branches of the ITA. ^, Fibers from the ansa cervicalis enter the muscle 3 cm above the sternal notch to complete the neurovascular bundle to the STh. ^{, ,}

Immediately superior to the STh is the smaller ThH muscle. It originates from the oblique line of the thyroid cartilage, following a vertical trajectory to the hyoid bone where it inserts into the inferior surface at the greater cornu just lateral to the insertion of the OMH, encompassing almost 2/3 of the cornu’s entire length. ^{, ,} In comparison to the rest of the strap musculature, a distinct feature of the ThH is its role in elevating the laryngeal cartilages beyond collective hyoid bone depression. ^, The ThH is innervated by fibers from the first cervical spinal nerve coursing within the hypoglossal nerve, emerging distal to the branching of the descendens hypoglossi. ^{, ,} Proximal to the insertion of the stylohyoid into the hyoid and superior to the tip of the greater cornu, the nerve to the ThH takes off, descending anteriorly into the anterior surface of the ThH muscle. ^, While evidence for the vascular supply to the ThH is largely lacking, a study by Wang et al. noted a branch of the STA proximal to the cricothyroid artery (CTA), presumably the IhA, piercing the ThH in 75% of cases.

Thyroid gland

The thyroid gland originates from an endothelial thickening between the first and second pharyngeal pouches within the developing pharyngeal floor, namely the foramen cecum at the base of the tongue. ^, The resulting diverticulum gives rise to the thyroid primordium, which descends anterior to the hyoid bone and laryngeal cartilages to reach the lower neck. ^, During descent, the thyroid primordium remains attached to the tongue by the thyroglossal duct, a tract that later involutes. Failure of this involution manifests clinically as a thyroglossal duct cyst. In adults, the thyroid gland assumes a butterfly shape as the isthmus connects the lateral lobes. It sits anterior to the trachea and larynx with the isthmus overlying the second and third tracheal rings ( Figure 1 C). ^{, ,}

For the head and neck surgeon, the thyroid is a major surgical landmark. It weighs approximately 15-25g, typically weighing less in biological females and more in biological males. ^, The thyroid lobes typically measure 4.5 cm in length and 2.3 cm in width near their base, also known as the inferior thyroid poles. ^{, , , ,} The isthmus typically measures 1.5 cm in height and 1 cm in width. ^{, ,} Arising from the lateral aspects of each thyroid lobe is the tubercle of Zuckerkandl (TZ), a prominence of thyroid tissue projecting posterolaterally. ^, In a study done on 104 thyroid lobes, the tubercle was present in 78% and 76% of right and left lobes respectively, and when identified serves as a useful landmark for identifying the recurrent laryngeal nerve (RLN), which is found deep to the gland prior to entering the larynx. Embryologically, the TZ originates from the ultimobranchial body, which is derived from the fourth and fifth branchial pouches, in contrast to the rest of the thyroid gland that predominantly arises from the median endodermal thickening on the floor of the primitive pharynx. ^{, ,} Its distinct embryologic origin allows for the TZ’s significance in thyroid surgery, which stems from its consistent anatomical relationship with the RLN. Given the RLN’s critical function in voice modulation through laryngeal muscle innervation, its preservation during thyroidectomy or neck dissection is paramount to prevent postoperative vocal cord paralysis. The TZ serves as a reliable landmark for locating the RLN as the nerve frequently courses medial and posterior to this structure. ^, Thus, surgeons may utilize the TZ to anticipate the RLN’s location, thereby minimizing the risk of nerve damage.

The pyramidal lobe (PL), present anywhere from 43-80% of the time, is thought to be a remnant of the thyroglossal duct. ^, A systematic review and meta-analysis of 24 studies encompassing 8,284 thyroids by Ostrowski et al. concluded that the PL typically measures 2.3 cm in length and 1 cm in width. Of these, the most common variation were PLs arising from the left thyroid lobe, as seen in 40% of cases, followed by PLs arising from the right thyroid lobe (25%).

The thyroid lobes are anchored to the laryngeal framework by Berry’s ligament, a condensation of the deep cervical fascia. ^, The ligament originates from the posteromedial aspect of each lobe and attaches to the inferior margin of the cornu of the thyroid cartilage, and first and second tracheal rings. A systematic review and meta-analysis by Henry et al. found the RLN to be located superficial (i.e. lateral) to Berry’s ligament in 78% of cases. During thyroid surgery, Berry’s ligament is often identified as the RLN is found entering the larynx, and division of Berry’s ligament to remove the thyroid can pose risk to the nerve if care is not taken during this step. The vascular supply of the thyroid gland is derived mainly from the STA and ITA, with minor contributions from the thyroid ima artery when present. ^, Often the first branch of the external carotid artery (ECA) arising from its anteromedial surface, the STA’s course in the neck proceeds lateral to the TH muscle and is accompanied by the EBSLN. ^, A systematic review and meta-analysis by Cheruiyot et al., the EBSLN was found to cross the STA within 1 cm above the superior pole of the thyroid in 42% of cases with the course of the STA lateral to the EBSLN in 71% of cases. ^, However, topographical relationships between the STA and the EBSLN are highly variable and caution should be exercised when approaching this region.

Once the STA reaches the level of the superior pole of the thyroid, it splits into the major glandular branches prior to entering the capsule, most commonly the anterior (ventromedial) and posterior (dorsolateral) branches. ^{, ,} The ventromedial branch supplies the anterior surface and anastomoses with its contralateral counterpart while the dorsolateral branch descends along the posterior border of the lobe to supply the medial and lateral surfaces, anastomosing inferiorly with the ITA. ^{, , ,} At the inferior pole of the thyroid, the ITA serves as the main blood supply. After taking off from the thyrocervical trunk, the ITA proceeds anterior to the vertebral artery and posterior to the sympathetic trunk and the carotid sheath, coursing anterior to the medial border of the scalene muscle. Just before reaching the level of the transverse process of the sixth cervical vertebrae, the ITA has a sharp, distinct loop as it turns anteromedially towards the inferior pole of the thyroid, branching into anterior and posterior components. ^, The relationship of the artery with the RLN is a matter of debate in the surgical literature, yet reasoning for depicting the RLN either superficial or deep to the ITA on the left but superficial on the right was discussed by Sankar et al ( Figure 2 ). ^, Briefly, the RLN on the left is more commonly found deep to the ITA. However, this relationship is flipped on the right, as the RLN is located superficial to the ITA in most individuals. Lastly, a relatively rare but clinically relevant anatomical variation in thyroid blood supply is the presence of a thyroid ima artery. When present, it arises most commonly from the brachiocephalic trunk, often coinciding with absence of at least one of the 4 arteries supplying the thyroid. As it courses superiorly from its origin to supply the thyroid, the ima artery lies anterior to the trachea and is therefore at risk of injury during tracheotomy. ^,

Lateral views of relevant structures in the central neck. (A) Left lateral oblique illustration that highlights the relationship of the superior and inferior parathyroids to the recurrent laryngeal nerve (RLN). It is common teaching that the superior parathyroids lie posterior to the coronal plane of the RLN and the inferior parathyroids anterior to that plane. Also shown are the cricopharyngeus muscle (CP), the left external branch of the superior laryngeal nerve (EBSLN), the superior thyroid artery (STA), the cricothyroid branch of the STA, and the inferior thyroid artery (ITA) travelling posterior to the RLN. (B) Right lateral oblique view of relevant structures in the central neck. This illustration highlights the relationship of the right recurrent laryngeal nerve (RLN) as it travels posterior/deep to the inferior thyroid artery (ITA).

Parathyroid glands

The parathyroid glands (PTG) are 4 in number and typically sit immediately posterior to the thyroid gland. ^, The 4 PTGs are grouped into 2 pairs, superior and inferior PTGs. The location of the superior PTGs is more predictable than that of their inferior counterparts as their embryonic origin from the fourth pharyngeal pouch allows for a shorter path during development. ^, On the other hand, the inferior PTGs arise from the third pharyngeal pouch along with the thymus. ^, The inferior PTGs follow the thymus on its inferomedial course to the mediastinum, explaining their location anterior to a coronal plane determined by the superior PTGs, and accounting for the higher rates of ectopic inferior PTGs anywhere along this large area of descent up to the superior border of the pericardium ( Figure 2 A). ^, The recurrent laryngeal nerve serves as an important landmark in this regard during central neck surgery, as the superior PTGs are situated posterior to the coronal plane of the RLN while the inferior PTGs are situated anterior to this plane.

Typically located within the superior and inferior boundaries outlined by the superior and inferior thyroid poles, the superior PTGs are found posterior to the middle third of the thyroid lobes in 56-61% of cases. Akerstrom et al. found 80% of superior PTGs (out of 503 autopsies) to be confined to a 2 cm in diameter region located 1 cm above the intersection of the RLN and the ITA. The inferior parathyroid glands are more variable in location, though are found close to the inferior thyroid pole (generally inferior, lateral, or posterior) in up to 60% of cases. ^, The ITA is a reliable landmark to identify the location of the PTGs, as the superior and inferior PTGs tend to be superior and inferior to the ITA, respectively. ^,

Frequently, the vascular supply to all 4 PTGs arises from glandular branches of the ITA ( Figure 2 B). ^, This observation was noted by Hollinshead and later described by Alveryd in 86% and 77% of the 354 right and left necks dissected, respectively. ^, Accompanied by the inferior PTGs along its descent from the third pharyngeal pouch, the thymus sits in the anterior mediastinum, though its superior aspect can be found in the lower central neck especially in younger individuals. Given its embryologic association with the inferior PTGs, a common location for an ectopic PTG is within the thymus. ^,

Arteries

The brachiocephalic, left common carotid (CCA), and left subclavian arteries are the 3 major branches of the ascending aortic arch in the majority of individuals (79-83%). ^, In this context, the brachiocephalic artery is invariably the first branch. It courses obliquely for 4-5 cm after its origin proceeding anterior to the trachea on the right neck to the level of the right sternoclavicular joint, where it bifurcates into the right subclavian and CCA. ^, From here, the right CCA ascends approximately 11 cm (± 2 cm) to branch into internal and external carotid arteries (ICA and ECA, respectively). ^, On the other hand, the left CCA originates directly from the aortic arch, and extends 12 cm superiorly from its origin to the level of its bifurcation. ^,

The CCAs mark the lateral borders of the central neck ( Figure 3 ). The CCA normally gives off no branches and terminates at the bifurcation before giving off the external carotid and internal carotid arteries, though rare reports of anatomical variants where the STA or lingual artery arise from the CCA exist. ^, The STA branches off of the anterior surface of the ECA just inferior to the greater cornu of the hyoid bone. ^, Prior to reaching the upper pole of the thyroid via the glandular branches, it gives off 4 branches: infrahyoid (IhA), superior laryngeal artery (SLA), sternocleidomastoid (SCM), and cricothyroid (CTA) arteries. ^{, ,} The IhA is the first of these branches and arises from the STA in 85% of cases, running along the inferior border of the hyoid, deep to the thyrohyoid membrane. In a similar manner, the SLA arises most commonly from the STA, approximately 0.5 cm from its origin, as found in 78% of cases out of 142 specimens by Vazquez et al . The SCM branch arises from the STA in 80% of cases and descends laterally across the carotid sheath to reach the middle third of the SCM. Once split into glandular branches, the CTA branches from the anterior glandular branch of the STA in 70% of cases, crosses high on the anterior cricothyroid ligament, and anastomoses with its contralateral counterpart to supply the cricothyroid muscle. ^,

Posterior view of relevant structures in the central neck. This illustration highlights the differences in the trajectory of the recurrent laryngeal nerves (RLN). The left RLN loops underneath the aortic arch (not shown) and, therefore, has a more parallel course within the tracheoesophageal groove as it ascends toward its insertion at the cricothyroid junction. In contrast, the right RLN loops underneath the right subclavian artery, and has a more oblique course as it ascends to its insertion point. Also highlighted are the superior thyroid artery (STA), the inferior thyroid artery (ITA) as it branches from the thyrocervical trunk (TcT), the parathyroid perforators originating from the ITA, Berry’s ligament, and the left and right subclavian arteries (LSA and RSA, respectively).

Of the 7 segments of the ICA, only the first is found in the central neck, referred to as the cervical segment and extending from the carotid bifurcation to the entrance of the carotid canal of the temporal bone. Throughout this segment, the ICA is found within the suprahyoid carotid sheath and does not give off any branches. ^, Superiorly, the carotid sheath attaches to the skull base on the vaginal process anteriorly and to the fibrocartilaginous tissue around the jugular foramen and carotid canal posteriorly. At the thoracic inlet, the carotid sheath inserts into the aortic arch and trifurcates into the thorax as 3 separate sleeves encasing each component along their route. ^{, ,} Within the carotid sheath, the ICA lies medial to the internal jugular vein (IJV). ^, In contrast, the relationship between the vagus nerve (CN X) and the groove adjoining these vessels is rather variable, including asymmetry between left and right sides. ^, Out of 50 cadavers, Hojaij et al. found CN X to course along the posterior surface of this groove on the right side in 64% of cases while resting on its anterior surface on the left in 68% of cases. ^,

Nerves

CN X leaves the cranial cavity through the pars vascularis of the jugular foramen, pierces the carotid sheath, and descends into the thorax. Given its long course, spanning 3 major body cavities, we will focus our discussion on its contributions to the central neck. As CN X exits the skull distal to the jugular fossa, accompanied by the IJV and CN IX and XI, a ganglionic chain is noted on the nerve’s surface, comprised by the superior (jugular) and inferior (nodose) ganglia. ^, Although anastomoses among these ganglia, CN IX, and the superior cervical ganglion (SCG) are complex and beyond the scope of our review, several plexuses arise from a mixture of branches from these structures. These include the pharyngeal and intercarotid plexuses.

Emerging caudal to the pharyngeal branches of the nodose ganglion, the superior laryngeal nerve (SLN) initiates its descent in the neck. ^, En route to the thyrohyoid membrane, the SLN exits the carotid sheath approximately 2 cm superior to the carotid bifurcation, crossing superficial to the SCG and deep to the ICA, where it branches into internal and external branches (IBSLN and EBSLN, respectively). ^{, ,} A comprehensive cadaveric study of 80 preparations on the course of the SLN found 95% of SLNs split into IBSLN and EBSLN, approximately 1.5 cm distal to the nodose ganglion. A loop of sympathetic fibers from the SCG joins the EBSLN immediately after branching, providing sympathetic innervation of the thyroid gland. The EBSLN is, on average, 8 cm long as it descends on the inferior pharyngeal constrictor and curves anteromedially just under the oblique line of the thyroid cartilage and coursing over the cricothyroid muscle to innervate it. ^, As for the IBSLN, it courses 7 mm anteroinferiorly from its start immediately inferior to the greater cornu of the hyoid to where it pierces the thyrohyoid membrane accompanied by the SLA.

CN X seldom branches at the level of the carotid triangle. Instead, it continues into the root of the neck encased by the carotid sheath. Once in the mediastinum, the RLN branches off CN X, coursing distinct paths between right and left sides . At the level of the subclavian artery, the right CN X is found anterior to it, where the right RLN takes off looping around the vessel. From here, it is found posterior to the right CCA as its course takes an oblique orientation toward the tracheoesophageal groove. ^, The left RLN travels deeper in the neck, branching off CN X at the level of the thoracic inlet. At the level of the aortic arch, it is found anterior to the arch before looping around the vessel. Once situated posterior to the aortic arch, the left RLN commences a slightly vertical path to the tracheoesophageal groove in comparison to its right counterpart. A detailed recount on the course of the RLN can be found in previous work by our team.

Veins

The superior thyroid vein (STV) drains the superior portion of the thyroid gland and travels alongside the STA, piercing the carotid sheath and emptying into the IJV. ^, In contrast, the remaining thyroid veins course in an independent vascular bundle. The middle thyroid vein emerges from the posterolateral edge of the middle third of the lateral lobes of the thyroid. From here it courses laterally, maintaining its superficial relationship to the RLN and crossing the CCA on its superficial surface to drain into the IJV near its lower third. ^, The inferior thyroid vein (ITV) emerges from the glandular plexus that connects the superior and middle thyroid veins with the ITV. Two main trunks, the right and left ITVs, descend anterior to the trachea to drain into the left brachiocephalic vein. ^, It is not uncommon for these veins to merge into a common trunk, the thyroid ima vein, and empty into the left brachiocephalic vein. Similarly, the ITV on the right may drain into the junction of both brachiocephalic veins.

Deep to the platysma and the superficial layer of cervical fascia, a confluence of superficial submandibular veins merge into the anterior jugular vein at or near the level of the hyoid. ^, The anterior jugular vein has variable communications with the retromandibular or facial veins and the IJV. ^, From here, it descends superficial to the infrahyoid muscles, approximately 1 cm lateral to midline and approaching the deep surface of the anterior border of the SCM. ^, As it approximates the manubrium, left and right anterior jugular veins are united by a transverse jugular arch prior to draining into the EJV near its confluence with the IJV. ^,

Lymphatics

The superficial and deep layers of the deep cervical fascia comprise the superficial and deep boundaries of the central neck, respectively. ^, The neck dissection lymph node classification proposed by Robbins et al. and adopted by the American Academy of Otolaryngology – Head and Neck Surgery refers to this space as level VI. The CCA bounds level VI bilaterally, while the hyoid bone and the suprasternal notch serve as its superior and inferior boundaries, respectively ( Table 1 ). ^, Lymph nodes in this compartment include the pretracheal, paratracheal, and Delphian nodes. On average, lymph nodes within this compartment measure 3 mm and total 18 nodes across 4 distinct regions ( Figure 4 ). ^, However, this number is highly variable between individuals.

Table 1

Level VI boundaries ^{, , ,}

Boundary	Radiological criteria	Surgical criteria	Radiation oncology criteria
Level VI
Superior	Inferior border of the body of the hyoid bone	Hyoid bone	Inferior edge of the thyroid cartilage
Inferior	Superior edge of the manubrium sternum bone	Superior edge of the manubrium sternum bone	Superior edge of the manubrium sternum bone
Lateral/Posterior	Medial border of the CCA	Common carotid artery	Common carotid artery
Medial	Medial border of the CCA	Common carotid artery	Common carotid artery
Deep	n/a	Laryngeal framework superiorly and trachea inferiorly	Anterior aspect of larynx, thyroid gland, and trachea
Anterior	n/a	n/a	Anterior border of the SCM and posterior edge of the thyrohyoid muscle

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