Quick accesses on a neck....409
Neck [collum (RShch, JNA, BNA)]. Upper bound of III. the line passing on bottom edge of a mandible, a top of a mastoid, the upper nuchal line and an outside occipital ledge is. The lower bound is made by edge of jugular cutting of the handle of a breast, the upper surface of a clavicle and the line connecting akromion to an acantha of the VII cervical vertebra.
More often a neck has the cylindrical form. Children and women have it more roundish and short, than at men. Skin of III. at children and persons of young age it is elastic and fits all ledges and poles of a neck (fig. 1) tightly. On a midline at cast away on -
Fig. 1. Relief of a perednebokovy surface of a neck: 1 — a contour of a ledge of a throat;
2 — a contour grudino - a clavicular and mastoidal muscle; z — a small supraclavicular pole; 4 — a contour of jugular cutting of the handle of a breast; 5 — a clavicle; 6 — a big supraclavicular pole; 7 — a projection of a trapezoid muscle.
the back to the head from top to bottom from a chin is probed the body and big horns of a hypoglossal bone, a thyroid cartilage, a cricoid, the first cartilages of a trachea covered with an isthmus of a thyroid gland. Below clearly the contour of jugular cutting of the handle of a breast is visible. From sides from a midline contours grudino - a clavicular and mastoidal muscle come to light, and thin persons have also contours of superficial veins of Highway.
Hypodermic cellulose Sh. is in front mobile, contains skin branches of a cervical plexus (see), the superficial veins of Sh. presented outside, front, and sometimes and median by jugular veins (vv. jugulares ext., ant. et mediana), on the course to-rykh two groups are located superficial cervical limf, nodes (nodi lymphatici cervicales superficiales).
Muscles of a neck (fig. 2) divide on superficial, average, deep lateral and deep medial groups. Carry a hypodermic muscle of a neck (m. platysma) and a grudino-klyuchichnosostsevidny muscle to superficial group (t. sternoclei-domastoideus). The average group includes the muscles of a hypoglossal bone lying as is lower than this bone (subhypoglossal muscles, T.) — scapular and hypoglossal (m. omohyoideus), grudinopodjyazychny (t. sternohyoi-deus), grudinoshchitovidny (m. sternothyroideus), shchitopodjyazychny (m. thyrohyoideus), and above it (nadpodjyazychny muscles, T.) — biventral (m. digastricus), chelyustnopodjyazychny (m. mylohyoideus), shi-lopodjyazychny (t. stylohyoideus), geniohypoid (t. ge-niohyoideus) muscles. The deep lateral group is formed by front, average and back scalenes (mm. scaleni ant., medius et post.), deep medial group — a long muscle of the head (t. longus capitis), long muscle of a neck (t. longus colli), front and lateral direct muscles of the head (mm. rectus capitis ant., rectus capitis lat.).
Distinguish back, or nuchal, area of a neck (regio cervicalis post., s. regio nuchae) and its front department with a number of areas and triangles (tsvetn. tab., Art. 176, fig. 5). Border between front department and back area Sh. are lateral edges of trapezoid muscles.
The front department of Sh. includes front area Sh. (regio cervicalis ant.), pair grudino-klyuchichnosostsevidny areas (regiones sterno-cleidomastoideae) and pair lateral triangles, or areas (trigona cervicalia lat., s. regiones cervicales lat.). Lateral triangles are known also under the name of the supraclavicular area (regio supracla-vicularis).
Fig. 2. The diagrammatic representation of muscles of a neck (skin, hypodermic cellulose, superficial and deep plates of own fascia of a neck are removed): 1 — a maxillary
hypoglossal muscle; 2 — a front abdomen of a biventral muscle; 3 — a hypoglossal bone; 4 — a shchitopodjyazychny muscle; 5 — the lower constrictor of a throat; 6 — an upper abdomen of a scapular and hypoglossal muscle; 7 — a grudinopodjyazychny muscle; 8 — grudino - a clavicular and mastoidal muscle; 9 — a trapezoid muscle; 10 — the lower abdomen of a scapular and hypoglossal muscle; 11 — a back scalene; 12 — an average scalene; 13 — a front scalene; 14 — the muscle raising a shovel; 15 — a belt muscle of the head; 16 — a hypoglossal and lingual muscle; 17 — a back abdomen of a biventral muscle; 18 — a shilopodjyazychny muscle.
In front area of a neck there are two medial triangles, each of to-rykh is limited to bottom edge of a mandible, to lobbies to r and I eat r at dynes ok l yu chichn about - from an ostseva d-ache muscles and a midline. In each triangle distinguish triangles of the smaller sizes. Submaxillary (podiizhnechelyustny, T.) the triangle (trigonum submandi-bulare) is limited to bottom edge of a mandible and both paunches of a biventral muscle. Its small site where the lingual artery can be naked, is called a lingual triangle (trigonum lin-guale), or Pirogov's (trigonum Pirogowi) triangle, borders to-rogo the rear edge of a che-lyustno-hypoglossal muscle, from above the site of a hypoglossal nerve, behind and from below a sinew of a biventral muscle are in front. The sleepy triangle (trigonum caroticum) is located between a back abdomen biventral, a first line grudino - clavicular and mastoidal and an upper abdomen lopatochnopodjyazychny muscles. The scapulartracheal triangle (trigonum omotracheale) is limited by a midline, an upper abdomen lopatochnopodjyazychny and a first line grudino - clavicular and mastoidal muscles. Mental (submental, T.) the triangle (trigonum submen-tale) is unpaired, it is between front paunches of both biventral muscles and a hypoglossal bone.
The lateral triangle pair, is located between the rear edge grudino - clavicular and mastoidal both with a first line trapezoid muscles and a clavicle. The lower abdomen of a scapular and hypoglossal muscle divides it into a scapularclavicular triangle (trigonum omoelaviculare) limited to a clavicle, the lower abdomen scapular and hypoglossal and the rear edge grudino - clavicular and mastoidal muscles (I pass in it outwardly a jugular vein, a nadlopatochny artery and a vein, at the left a chest channel, on the right the right lymphatic channel), and a scapular and trapezoid triangle (trigonum omotrapezoideum) located between a first line trapezoid, the rear edge grudino-klyuchichnosostsevidny and the lower abdomen scapular and hypoglossal muscles. In lopa chno - t r and petsy visible to t r eu go the l to from under the rear edge grudino - a clavicular and mastoidal muscle on border of upper and its average third leaves an eleventh cranial nerve (n. accessorius), to-ry passes in an upper corner of a triangle and under a trapezoid muscle. In an internal corner of this triangle ahead of a front scalene and a brachial plexus there is a superficial cervical artery. In a medial part of a triangle branches of a brachial plexus and the cross artery of a neck (a. transversa colli) passing between them are located.
Between scalenes there are two triangular spaces — interladder space (spatium interscalenum) limited to front and average scalenes, and from below — the I edge (in it there pass the subclavial artery and a brachial plexus), and predlest-nichny space (spatium ante-scalenum) located between a front scalene behind and grudinoshchitovidny and grudinopodjyazychny muscles in front (in it there pass the subclavial vein, a nadlopatochny artery and a phrenic nerve).
The listed areas and Sh.'s triangles serve as reference points at neck operations.
Muscles and Sh.'s bodies are surrounded with fastion (see). The anatomy fastsy Sh. is difficult, and opinions of different researchers on their quantity are contradictory. On PNA, there is a uniform cervical fascia (fascia cervicalis), in a cut allocate three plates — superficial (lamina superficialis), pretracheal (lamina pre-trachealis), prevertebral (lamina prevertebralis) — and a sleepy vagina (vagina carotica). The greatest recognition was gained by the classification fastsy Sh. offered V. N. Shev-kunenko. According to this classification allocate five fastion, or fascial layers (tsvetn. tab., Art. 176, fig. 7). The first superficial fascia (fascia superficialis) is a part of the general superficial fascia of a body and forms on a neck a vagina for a hypodermic muscle of Highway. The second fascia — a superficial plate of own fascia (lamina superficialis fasciae colli propriae) corresponds to a superficial plate of a cervical fascia (on PNA), is attached from below to front surfaces of a clavicle and breast, from above to a mandible, behind reaches awned, and from sides of cross shoots of cervical vertebrae, forming spurs, to-rye connect the second fascia to a heel and a vagina of a neurovascular bunch; the second fascia forms vaginas for grudino-klyuchichnosostsevidny and trapezoid muscles and submaxillary (podnizhnechelyust-ache, T.) glands. The third fascia — - a deep plate of own fascia of a neck (lamina profunda fasciae colli propriae), or a lopatochnoklyuchichny aponeurosis (aponeurosis omoclavicularis), corresponds to the second (pretracheal) plate (on PNA), has the form of a trapeze, is located between a hypoglossal bone from above and a back surface of a clavicle and breast from below; forms vaginas for scapular and hypoglossal, grudinopodjyazychny, grudinoshchitovidny, shchitopodjyazychny muscles. On the centerline the second and third a fascia grow together, forming the so-called white line of a neck. The fourth — an intra cervical fascia (fascia endocervicalis) has parietal and visceral plates. The visceral plate surrounds a throat, a throat and a thyroid gland. The parietal plate surrounds internals of Sh. and forms a case for a neurovascular bunch
of III., including the general carotid artery, an internal jugular vein and a vagus nerve. The fifth — a prevertebral fascia (fascia prevertebralis) corresponds to a predpozvo-night plate of a cervical fascia (on PNA), is located kzad from internals of a neck and covers a sympathetic trunk, long muscles of a neck and the head, forms a vagina for scalenes.
Interfascial kletchat internal spaces (see) necks matter at distribution of inflammatory processes. The Nadgrudinny interaponeurotic space (spatium interaponeuroticum supras-ternale) is between superficial and deep plates of own fascia of a neck over jugular cutting of the handle of a breast, In its friable cellulose there passes the jugular venous arch (an anastomosis of the right and left front jugular veins) and sometimes limf. nodes. The Nadgrudinny interaponeurotic space is reported with a cul-de-sac (saccus caecus) located behind grudino - a clavicular and mastoidal muscle (m. sternocleidomastoideus), in Krom there is a final department of a front jugular vein, limf, vessels and nodes. Previsceral, or a prebang-alnoye, the space (spatium rge-viscerale, s. spatium pretracheale) is located between parietal and visceral leaves of the fourth fascia and extends from a hypoglossal bone to the handle of a breast where passes into a front mediastinum. It is limited in front of grudinopodjyazychny and grudinoshchitovidny muscles, behind a throat and a trachea, from sides to vaginas of cervical sosudistonervny bunches. In cellulose of pre-visceral space there is an unpaired thyroid veniplex, limf, vessels and nodes. The Klet-chatochny space concluded in a case of a neurovascular bunch of Sh. proceeds in cellulose of a front mediastinum, subclavial and axillary areas. In a circle of nasal and oral parts of a throat the parapharyngeal space is located, in Krom distinguish front and back departments. Serve as border between departments an awl-shaped shoot with the muscles departing from it and a fascial leaf, to-ry lasts between it and a throat. From a pharyngeal cavity the parapharyngeal space is adjoined by a palatine tonsil, outside — a parotid gland. In front department of parapharyngeal space there pass branches of the ascending palatal artery and the veins of the same name. In back department the internal jugular vein, an internal carotid artery, the glossopalatine, wandering, additional, hypoglossal nerves, and also a sympathetic trunk are located. The Pozadivistseralny space (spatium retroviscerale) limited to a visceral layer of the fourth fascia and a prevertebral fascia extends from a base of skull to a postmediastinum. Cellulose of this space passes below into cellulose of a postmediastinum.
In a scapular and trapezoid triangle of supraclavicular area lies kletchatochny to space, a cut it is reported with the kletchatochny space located under a trapezoid muscle.
Skeleton of III. — cervical department of a backbone (see), muscles and fastsip form a musculoskeletal cavity, in a cut bodies of III are located. — a throat (see), a cervical part of a trachea (see), a thyroid gland (I eat.), epithelial bodies (see), a throat (see), a cervical part of a gullet (see).
The throat is located on level of IV— VI of cervical vertebrae, below a hypoglossal bone, below passes into a trachea. In front the throat is covered with muscles, from sides shares of a thyroid gland adjoin to it, behind there is a throat.
The cervical department of a trachea is covered in front with an isthmus of a thyroid gland, grudinopodjyazychny and grudinoshchitovidny muscles: on the centerline of edge of these muscles disperse, forming pretracheal space together with fastion and a trachea. On each side from a trachea the general carotid arteries are located.
The thyroid gland consists of two side shares and an isthmus; approximately in V3 of cases the pyramidal shoot sometimes reaching a hypoglossal bone departs from an isthmus. The isthmus of gland lies on a front surface of a trachea at
the I—II level — the III or II—III — IV her cartilages. Side shares prilezhat behind to a trachea, a thyroid cartilage, a throat, a gullet and partially cover an average third of the general carotid arteries. The thyroid gland has own capsule and the fascial vagina formed by a visceral layer of the fourth fascia, in friable cellulose to-rogo vessels, nerves and epithelial bodies are located.
The throat begins at a base of skull and at the level of bottom edge
of the VI cervical vertebra, is funneled being narrowed, passes into a gullet. Distinguish nasal, oral and guttural speak rapidly drinks. Behind a guttural part of a throat the long muscles of a neck and a body of vertebrae covered with a prevertebral fascia, in front — a throat, from sides — upper poles of a thyroid gland and the general carotid arteries are located.
A cervical part of a gullet begins at the level of VII of a cervical vertebra, behind a cricoid of a throat. Below, kpered from a gullet, the trachea, behind — preposes-vonochnaya (fifth) fascia lies. Between a gullet and a trachea there is a groove (sulcus tracheoesophageus) at the left, in a cut there passes the left recurrent guttural nerve. The right recurrent nerve, the general carotid arteries and the lower poles of side shares of a thyroid gland are located from sides from a cervical part of a gullet.
On Sh. there is a plentiful network of vessels and nerves. Supply with blood of muscles and Sh.'s bodies is carried out by branches of outside sleepy and subclavial arteries. Outflow of a venous blood happens in system of front, outside and internal jugular veins. Outflow of a lymph goes on deep limf, vessels to deep cervical limf, to nodes (nodi lymphatici cervicales profundi). Lobbies limf, nodes (nodi lymphatici cervicales profundi anteriores) located ahead of a throat, about a trachea and a thyroid gland, and lateral cervical (nodi lymphatici cervicales profundi laterales), going along an internal jugular vein, an eleventh cranial nerve and cross vessels of Highway distinguish. The taking-out absorbent vessels limf, nodes create the right and left jugular trunks (trunci jugulares dext. et sin.), to-rye collect a lymph from the corresponding half of the head and a neck and fall on the left side into the chest canal (ductus thoracicus), and on right — into the right lymphatic canal (ductus lymphaticus dexter).
The innervation of muscles is connected with their origin. The muscles derivative of the first visceral arch (maxillary and hypoglossal, a front abdomen of biventral), are innervated by a trifacial (see). The muscles derivative of the second visceral arch (shilopodjyazychny, a back abdomen of biventral) — a facial nerve (see). Derivatives of branchiate arches — grudino - clavicular and mastoidal to trapezoid muscles are innervated by an eleventh cranial nerve (see) and a cervical plexus (see). The autokhtonny origin and their innervation have other muscles it is carried out by front branches of cervical spinal nerves.
Pathology includes malformations, damages, zabolevaniye and tumors.
Malformations. The wryneck (see) happens both inborn, and acquired (e.g., at a miositis grudino - clavicular and mastoidal muscles).
Cervical edges occur preferential at women. They result from a delay of involution of the rudiments of cervical edges existing in the embryonal period. Are more often observed on VII, is more rare on others, and sometimes on all cervical vertebrae. Quite often happen bilateral. Long cervical edges, pressing in soft tissues of Sh., are jointed with the I edge or with the handle of a breast. After an injury of a shoulder girdle, a neck or a raising of weights, and also in connection with overfatigue of the muscles innervated by the lower cervical roots there can be paresthesias, pains in the field of brushes and a shoulder, weakness and bystry fatigue of hands. These symptoms are caused by a prelum of a brachial plexus and a subclavial artery cervical edges. At survey of the patient pay attention to low lowered shoulders. Sometimes scoliosis develops (see). In the field of a big supraclavicular pole dense education with not clear contours is palpated, Crimea iod is noted a pulsation of a subclavial artery. Blanching and a cold snap of a brush, weakening of pulse on humeral and beam arteries is quite often observed. Development of aneurism (see) or fibrinferment (see) a subclavial artery is possible. The diagnosis is established on the basis by a wedge, pictures and results rentgenol. researches. Differential diagnosis is carried out with a syndrome of a scalene, at Krom similar neurovascular frustration can be observed, but there is no cervical edge (see the Scalene a syndrome). At unsuccessfulness of conservative treatment removal of a cervical edge, sometimes with crossing of a front scalene (scalenotomy) or its excision throughout 4 — 5 cm is shown (scalenectomy). The section is made across Voskresensky in a big supraclavicular pole 3 cm higher by clavicles and parallel to it (fig. 3, in, 12), its extent depends on length of a cervical edge. After bandaging of a cross artery of a neck subclavial vessels take in medial, and a brachial plexus to the lateral party. The cervical edge is exempted from scalenes and deleted. The forecast in uncomplicated cases favorable.
Median and side cysts (fistulas) of a neck meet quite often and are subject to removal (see. Branchyogenic cyst, Fistulas).
Rare inborn deformation of Sh. is the so-called alate neck, at a cut there are two skin folds tense in the form of triangular sails from side surfaces of the head to nadilechyam. Sometimes in these folds there are large vessels and nerves. Treatment consists in plastic surgery of movement of counter triangles across Limberg (see the Person) or excision of skin folds and imposing of cosmetic seams (see. Skin plastics). Forecast favorable.
Damages. Distinguish the closed and open injuries of a neck. The closed damages arise at stupid blow, a strong push, falling on the head from height, at transport and agricultural injuries (see Traumatism), at Sh.'s prelum hands or a loop (see Strangulation), hanging (see). At the same time bruises of soft tissues (see the Bruise), fractures of cartilages of a throat (see), tracheas (see) and seldom hypoglossal bone can be observed. At blow by a firm subject and hanging dislocations and fractures of cervical vertebras are possible. The main direct danger at the closed Sh.'s damages are disturbance of breath (see Asphyxia) and sometimes a cardiac standstill, to-rye can come reflex owing to blow in a throat even in the absence of visible damages.
At treatment of the closed Sh.'s damages first of all recover breath by an intubation of a trachea (see the Intubation), and according to indications make a tracheostomy (see) or a konikotomiya (see the Laryngotomy). At a fracture of a hypoglossal bone the displaced fragments set, and at unsuccessfulness of anemic reposition resort to an operative measure (sewing together large, removal of small fragments). At fractures of cervical vertebras carry out an immobilization (see) cervical department of a backbone.
Among open injuries of a neck in peace time the wounds caused acute or pricking meet more often, is more rare firearms. Cut and chipped wounds of Sh., even superficial, are extremely dangerous and often lead to damages of bodies of Sh. since the distance from the surface of skin to large vessels and vitals is estimated in several millimeters. The clinical picture, diagnosis, treatment and the forecast of open damages of Sh. depend first of all on localization of damage (see the Throat, the Throat, the Gullet, the Trachea, the Thyroid gland). During surgical treatment of wounds (see) carry out audit of bodies of a neck, at the same time cut a chipped wound to the bottom. At wound of the general carotid artery (see. Carotid arteries), an internal jugular vein (see. Jugular veins) and their large branches according to indications put a vascular stitch (see) or tie up a vessel in a wound or on an extent (see Bandaging of blood vessels).
Except damages of bodies of a neck, the main vessels and a backbone, injuries of a recurrent guttural nerve, IX, X, XI and the XII craniocereberal meet (cranial,
T.) nerves (see Bluzhdayushchtsy a nerve, the Eleventh cranial nerve, the Hypoglossal nerve, the Glossopharyngeal nerve), a sympathetic trunk (see the Autonomic nervous system), a cervical plexus (see) and a brachial plexus (see).
Fighting damages sh e and in the period of the Great Patriotic War made apprx. 1% of all wounds. Depending on a type of weapon distinguish the bullet, missile wounds, wounds put with cold weapon (see Wounds, wounds).
Diagnosis of damages of bodies of Sh. at the advanced stages of medical evacuation shall be directed first of all to identification and prevention of life-threatening complications — asphyxia (see), bleedings (see), shock (see). The diagnosis of outside bleeding does not cause difficulties. At internal bleeding it is possible to observe the pulsing hematoma, weakening of pulse filling of a superficial temporal artery, vascular noise. Confirm disturbance of breath up to asphyxia injury of a throat or trachea, an air-out through a wound, the exhausting cough (see), a pneumorrhagia (see), disturbance of phonation, hypodermic emphysema (see). At the getting wounds of a throat and gullet disturbance of swallowing is observed, food or saliva can be allocated through a wound. Due to the weight of infectious complications of such injuries (a mediastinitis, deep phlegmons of Sh.) even the assumption of injury of a throat and a gullet is the indication to an urgent operative measure.
The first medical aid wounded in Sh. provides a temporary stop of outside bleeding by imposing on a wound of an aseptic bandage by means of a first-aid dressing kit. At the proceeding bleeding apply a bandage on Kaplana: the hand of the wounded which is thrown back for the head (on the party opposite to the side of damage of Sh.) fix by bandage, on a wound impose the wadded and gauze roller, to-ry densely fix to a wound bandage, carrying out it through a shoulder of the thrown-back hand. For prevention of aspiration of blood of such wounded who especially fainted stack facedown or sideways. At retraction of language use a S-shaped respiratory tube or, having punctured language with a safe pin and having a little extended it, fix the bandage which is carried out around III. At suspicion on damage of cervical department of a backbone it is immobilized by means of standard tires or make-shifts.
On regimental medical aid station (see) correct a bandage, an immobilization, enter antitetanic serum, antibiotics, at disturbance of breath make a tracheostomy (see), clear upper respiratory tracts by means of a suction. Sometimes the tracheostomy tube is entered through a wound of a front or perednebokovy surface of Sh. (an atypical tracheostomy). According to indications perform inhalation of oxygen and artificial ventilation of the lungs by means of respiratory devices (see. Oxygen therapy). Bleeding is stopped by a tamponade of a wound, bandaging of the damaged vessel or imposing on it a styptic clip. At traumatic shock the wounded hold antishock events (see Shock).
At a stage of rendering the qualified medical aid according to indications carry out a complex of antishock therapy, a tracheostomy, a final stop of bleeding (bandaging of vessels in a wound or on an extent), outside drainage of wounds of a throat and gullet. Food of such victims is carried out by means of the probe entered through a nose or a mouth at impossibility — through a wound of the digestive channel. Wounded with injuries of a neck are evacuated in specialized to lay down. institutions.
Diseases. Acute and chronic nonspecific inflammatory diseases of Sh. most often cause pyogenic bacteria (see), sometimes anaerobe bacterias (see), especially asporous (neklostridialny). Purulent lymphadenitis and Sh.'s phlegmon quite often develop in connection with existence of the centers of an infection in carious teeth (see Caries of tooth), at quinsy (see), in particular to Ludwig's quinsy (see Ludwig quinsy), pharyngitis (see), laryngitis (see), a thyroiditis (see), purulent diseases of sialadens (see), face skin and a pilar part of the head, nurseries inf. diseases, and also at wound of a gullet (see), drinks (see), throats (see), etc.
To nonspecific inflammatory diseases of III. carry an anthrax (see), lymphadenitis (see), I will give rise (see), phlegmon (see), to a furuncle (see).
Damage of a neck at an ugly face (see) proceeds hard, quite often is complicated by meningitis (see) and sepsis (see).
Lymphadenitis is the most frequent inflammatory disease of Highway. The acute inflammation superficial cervical limf, nodes quite often is complicated superficial флег^ by Mona III. The inflammation deep cervical limf, nodes often leads to development of deep phlegmon of Highway. Chronic lymphadenitis of Sh. is more often observed at children and shown by increase limf, nodes, to-rye are, as a rule, painless, are not soldered among themselves and to surrounding fabrics. The differential diagnosis is carried out with tuberculosis limf, nodes (see Tuberculosis extra pulmonary) and malignant tumors (see). Before treatment of chronic lymphadenitis sanitation of an oral cavity is obligatory (see). The forecast in uncomplicated cases favorable.
The most serious inflammatory illness of Sh. demanding sometimes the emergency operative measure is phlegmon, edges can be localized in any kletchatochny space of Sh. Obychno Sh.'s phlegmon proceeds sharply, except for so-called ligneous phlegmon to Rekl (see Phlegmon). Features of an anatomic structure of Sh. promote bystry distribution of purulent process from one kletchatochny space of Sh. on others and even on a mediastinum (see), in a cavity of a skull (see), an axillary pole (see), a subclavial pole (see. Subclavial area), on a front chest wall. So, the purulent process which is localized between superficial and own fastsiyama, can go down retro mammarno, the process which developed between visceral and parietal leaves of an intra cervical fascia — to extend in an afterbreast and a mediastinum, and the process which is localized between a visceral layer of an intra cervical fascia and a prevertebral fascia — in a postmediastinum. At defeat of cellulose of a neurovascular bunch pus spreads in a mediastinum, and also to subclavial and axillary areas. Features wedge, courses of phlegmons of III. depend on localization of process and define the choice of a method of an operative measure
. Superficial (hypodermic) phlegmon of III. it is shown by a hyperemia, morbidity and puffiness of skin. Local temperature and body temperature increases. The suppurative focus is localized, as a rule, under a hypodermic muscle of III., densely connecting to skin. Superficial phlegmon of Sh. is opened cross or the slit which is carried out to own fascia of a neck and drained. For the purpose of prevention of an air embolism it is necessary to spare the outside jugular vein lying under a hypodermic muscle.
Phlegmon of a bed grudino - a clavicular and mastoidal muscle often arises owing to a mastoiditis (see). It is shown by the expressed pain syndrome and a swelling (kolbasovidny swelling) in a muscle. The head of the patient at first is inclined towards defeat; further at fusion of a muscle adopts the normal provision (Voyno-Yasenetsky's symptom). The fascia, perimuscular, long interferes with distribution of pus. At destruction of a front leaf of a fascia pus spreads under a hypodermic muscle of Sh., at destruction of a back leaf — in vascular and previsceral kletchatochny spaces and further in a mediastinum. The suppurative focus is opened with a slit over the affected muscle, sparing an outside jugular vein.
Phlegmon of nadgrudinny kletcha-exact space arises owing to lymphadenitis or osteomyelitis (see) handles of a breast. It is shown by a painful swelling and a smoothness of contours in the field of jugular cutting of a breast, existence of a so-called inflammatory collar. At destruction of a front wall of nadgrudinny kletchatoch-ny space pus gets into hypodermic cellulose. Big danger is constituted by destruction of a back fascial wall, at Krom purulent process can get for a breast and further into a mediastinum (see to Pus extends also on the course of front jugular veins under lower parts grudino - clavicular and mastoidal muscles and further in a mediastinum, to supraclavicular and axillary areas. Therefore early such phlegmon operation serves as prevention of the hardest purulent complications. Opening of a suppurative focus is carried out a slit from jugular cutting of a breast to a thyroid cartilage (fig. 3, and, 5). It is possible to use and cross access between front edges grudino - clavicular and mastoidal muscles is 2 cm higher than a breast.
Submaxillary and mental phlegmons are shown by a swelling and sharp morbidity in the respective area amplifying during the opening of a mouth and chewing, existence of a putrefactive smell from a mouth. At phlegmon of submaxillary area process can be localized in hypodermic cellulose or is thicker than submaxillary gland (see) and to be followed by a fever (see), sharp intoxication (see), gektichesky fever (see). The suppurative focus is opened with the section parallel to bottom edge of a mandible, otstupya from it on 2 cm from top to bottom and without reaching a first line of a masseter where there pass a facial artery and a vein (fig. 3, in, 10). At mental phlegmon the section is carried out between a chin and a hypoglossal bone.
Phlegmon of kletchatochny space of a neurovascular bunch of Sh. arises more often at quinsy. It is shown by sharp morbidity on the course grudino - a clavicular and mastoidal muscle, in the area the cut is defined a dense swelling, a positive symptom of Voyno-Yasenetsky. Pus accumulates in a fascial vagina of a neurovascular bunch from where it can directly pass into a mediastinum, and at destruction of a fascial wall of a vagina — in previsceral and pozadivistseralny spaces. Destroying a fascial vagina on the rear edge of a grudinoklyuchichno-mastoidal muscle, pus spreads to the supraclavicular area. Dangerous complications of this phlegmon are an arrosion of large vessels with profuse bleeding (see) and thrombosis of an internal jugular vein. Owing to pressure of inflammatory infiltrate upon a throat, a throat and a gullet disorders of breath and swallowing are quite often observed. Bilateral phlegmons of this area are described. The section for opening of phlegmon is carried out on an inner edge of a grudinoklyuchichno-mastoidal muscle from a corner of a mandible to jugular cutting of the handle of a breast. Cut skin, a hypodermic muscle and a superficial fascia and often already here find accumulation of pus. In the absence of pus carefully cut the fourth leaf of a fascia and bare a neurovascular bunch of Highway. After evacuation of pus provide drainage of the foot of an abscess. Carefully examine an internal jugular vein and in the presence of her thrombosis tie up a vein below (tsentralny) than blood clot. During operation it is necessary to be careful of injury of the arteries going in transverse direction in relation to a section, in particular the lower thyroid artery. When pus breaks to the area of the rear edge of a grudinoklyuchichno-mastoidal muscle, the section is carried out on this edge of a muscle from a clavicle to border of an upper and average third of a muscle, sparing the eleventh cranial nerve leaving here from under a muscle (at damage of it a nerveand the ducking of the patient in the healthy party and nek-ry turn towards defeat is noted). In a vascular bed pus quite often breaks at purulent parotitis (see); such became numb (see) shall be opened.
At phlegmon of previsceral space purulent process is localized between a trachea and a throat behind grudinopodjyazychny and in front of grudinoshchitovidny muscles. On a front surface of III. the painful swelling develops; the head of the patient is thrown a little back back, the movements are sharply painful; disorders of breath and swallowing, cyanosis of the person are often observed. During the opening of an abscess the section is carried out from a thyroid cartilage to jugular cutting of the handle of a breast (fig. 3, and, 5); at the same time the cricoid, an isthmus of a thyroid gland, a front surface of a trachea is bared. Purulent process of this kletchatochny space can easily get into a mediastinum therefore the section is conducted to healthy fabrics from top to bottom and provide outflow of pus from the lowest point of an abscess. At the phlegmons caused by wound of a throat and trachea the tracheostomy is shown.
Phlegmon of pozadivistseralny space develops at wound and the closed injuries of a gullet more often (tool researches, foreign bodys, etc.). Having arisen in paraezofagealny cellulose, it is purulent - necrotic process in connection with high virulence of microflora (frequent it is a не-клостридиальные anaerobe bacterias) quickly extends in a mediastinum (see the Mediastinitis), quite often being complicated by arrozivny bleeding from a carotid artery and osteomyelitis of vertebrae. Opening of phlegmon is carried out across Razumovsky — a section on a first line of a grudino-klyuchichnosostsevidny muscle (see the Gullet).
At suspicion on existence of deep phlegmon of Sh. always make a survey X-ray analysis of a neck, thorax and a X-ray contrast research of a gullet (see the Gullet, methods of a research). Existence of a wide shadow of a mediastinum can demonstrate development of a mediastinitis, and presence of gas at soft tissues — perforation of hollow body, is more often than a gullet. Fibroezofa-goskopiya (see Endoscopy) considerably facilitates diagnosis injury of a gullet.
X ronichesky nonspecific phlegmon of HI. (ligneous phlegmon to Rekl) it is observed usually at the weakened patients and it is caused by slabovirulentny microflora. Clinically it is shown by the dense, ligneous infiltrate sometimes occupying all neck, to-ry is covered with edematous, cyanotic skin. Along with hypodermic cellulose also deep kletchatochny spaces are surprised that can cause disorders of breath and swallowing (see Phlegmon). At an operative measure make multiple cuts for the purpose of opening of all klet-chatochny spaces of a neck.
In addition to an operative measure, at the listed above forms of phlegmon active antimicrobic treatment using antibiotics of a broad spectrum of activity is carried out.
Anaerobic phlegmon can affect any kletchatochny space of Highway. It quickly extends to other kletchatochny spaces of Sh. and the wedge, is characterized by a picture heavy. In a complex to lay down. actions early operation, adequate drainage, ensuring access of air to the struck fabrics, administration of polusin-tetichesky penicillin in high doses, etc. enter (see. Mephitic gangrene). At anaerobic phlegmon of hypodermic cellulose (anaerobic cellulitis) continuous defeat of cellulose usually is not observed; peripheral suppurative focuses in the form of nests are localized on various removal from the main center and can be surrounded with not changed cellulose. Therefore at treatment of hypodermic phlegmon use the multiple cuts providing opening of all centers or preventing further distribution of purulent process. At anaerobic phlegmon of deeper departments of Sh. process can extend to all kletchatochny spaces of a neck. In this case the most radical is Dyakonov's operation. The section is begun under a mandible on the party of defeat, otstupya from it on 2 cm, and conducted on a first line grudino - a clavicular and mastoidal muscle; without reaching 2 cm a clavicle, the section is turned by kzad and will see parallel to a clavicle to a trapezoid muscle (fig. 3, 7). In a lower part of access cross grudino - a clavicular and mastoidal muscle, reaching finally broad opening of all kletchatoch-ny spaces of a neck.
Fig. 3. The diagrammatic representation of quick accesses on a neck: and — an anterior aspect, and in — a lateral view; 1 — access for bandaging of outside and general carotid arteries and an internal jugular vein; 2 — cross access to a throat; 3 — upper median access for a laryngectomy; 4 — Kokher's access to a thyroid gland; «5 — access for a nishny tracheostomy, opening of previsceral space and a front mediastinum; 6 — access Petrovsky to a subclavial artery; 7 — Dyakonov's access; 8 — Krayl's access; 9 — Venglovsky's access; 10 — access for opening submaxillary flegmonvd; 11 — access for an exposure of a phrenic nerve; 12 — access for an exposure of a chest channel and a cervical edge.
The forecast at all forms of phlegmons at untimely treatment serious.
From specific inflammatory diseases of Sh. is more often than others tubercular and syphilitic defeats are observed. Tubercular process strikes hl. obr. lymph nodes of Sh., proceeds it is long, perhaps secondary infection is complicated by fistulas (see) (see Tuberculosis extra pulmonary). At primary syphilis when the hard ulcer is localized on a lip or in an oral cavity, on a neck appear dense, painless at a palpation, not soldered among themselves and to surrounding fabrics limf, the nodes which are located in the form of a chain. At secondary syphilis limf, nodes on a neck happen even more dense, the necklace of Venus — a so-called necklace of Venus is quite often observed. At tertiary syphilis on a neck there can be syphilomas (see Syphilis).
From fungus diseases of Sh. the greatest value has an actinomycosis (see) which can affect skin, hypodermic cellulose and limf. nodes. Meet a zymonematosis (see), histoplasmosis less often (see), etc.
To general diseases, at to-rykh defeats limf are observed, nodes of a neck, belong a lymphogranulomatosis (see), to a retik of a leza (see), a sarcoidosis (see), etc.
Tumors. Distinguish benign and malignant tumors of bodies and tissues of a neck. From high-quality adenomas of a thyroid gland or epithelial bodies (see Adenoma), a lipoma (see), fibroma meet (see) etc. Among malignant are observed branchyogenic cancer (see. Branchyogenic tumors, Cancer), cancer thyroid and epithelial bodies, tumors of a carotid glome, sarcoma of soft tissues (see Sarcoma) and some other. In limf, nodes of a neck metastasises at cancer of a lung, stomach are often localized — Virkhov's metastasis (see the Stomach, tumors), a thyroid gland, a mammary gland and other bodies.
Quick accesses on a neck
Krom of the quick accesses stated above at phlegmons of a neck, are offered numerous accesses, to-rye apply at operative measures on bodies of a neck. So, cervical and upper parts chest tracheas apply a slit from jugular cutting of the handle of a breast to a thyroid cartilage to an exposure or the cross section which is carried out 1 cm below than a cricoid (
fig. 3, and, 4 and 5). Use these cuts also for penetration into previsceral space and a front mediastinum. After an exposure of a front surface of a trachea in the stupid way get, sliding on it, in pretracheal space of a chest cavity. Accesses use at intense emphysema of a mediastinum, purulent zateka from previsceral space of Sh. in a front mediastinum, a biopsy bifurcation limf, nodes, a tracheostomy. At operations on cervical department of a gullet use access on a first line grudino - a clavicular and mastoidal muscle, offered V. I. Razumovskimmeney access on the rear edge of this muscle since at it damage of an eleventh cranial nerve is possible is preferable. Access to the general carotid artery and an internal jugular vein takes place on a first line of a grudino-klyuchichnosostsevidny muscle (fig. 3, and, 1). After a section of a parietal layer of an intra cervical fascia release a neurovascular bunch of a neck. For an exposure of a phrenic nerve the section of skin is carried out parallel to a clavicle, is 2 cm higher than it on an extent from the rear edge grudino - a clavicular and mastoidal muscle to a first line of a trapezoid muscle. It is possible to apply a slit on the rear edge grudino - a clavicular and mastoidal muscle from its middle towards a clavicle (fig. 3, in, 11). After a section of a prevertebral fascia the edge of a front scalene is bared; on a front surface of this muscle the phrenic nerve is located. The same access is used at so-called preskalen-ache biopsies limf, nodes, a scalenotomy and at operations on a chest channel (see. Grudnoy Canal) in the place of its falling into the left venous corner (fig. 3, in, 12). Access to an afterbreast provides a section over the handle of a breast. Cut a superficial fascia, stupidly divide cellulose nadgrudinny between aponeurotic space, cut own fascia and get into an afterbreast. Access is applied at intense emphysema of a mediastinum, purulent zateka in an afterbreast. During removal of the big tumors which are localized on a neck apply Dyakonov's accesses (fig. 3, 7), Krayla (fig. 3, 8) and Venglovsky (fig. 3, in, 9). Also accesses to a throat (fig. 3, and, 2), throats (fig. 3, and, 3), a thyroid gland (fig. 3, and, 4), etc. are developed.
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