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Congenital Torticollis
Torticollis (L. tortus, twisted + L. collum, neck) is a contraction or shortening of the
cervical muscles that produces twisting of the neck and slanting of the head. The most common
type of torticollis (wry neck) results from a fibrous tissue tumor (L. fibromatosis colli) that
develops in the SCM before or shortly after birth. The lesion, like a normal unilateral SCM
contraction, causes the head to tilt toward, and the face to turn away from, the affected side (Fig.
B8.1). When torticollis occurs prenatally, the abnormal position of the infant's head usually
necessitates a breech delivery.
Occasionally, the SCM is injured when an infant's head is pulled too much during a difficult
birth, tearing its fibers (muscular-torticollis) (Behrman et al., 2000). A hematoma (localized mass
of extravasated blood) occurs that may develop into a fibrotic mass that entraps a branch of the
spinal accessory nerve (CN XI) and thus denervates part of the SCM. The stiffness and twisting
of the neck results from fibrosis and shortening of the SCM. Surgical release of the SCM from its
inferior attachments to the manubrium and clavicle inferior to the level of CN XI may be
necessary to enable the person to hold and rotate the head normally.
Spasmodic Torticollis
Cervical dystonia (abnormal tonicity of the cervical muscles), commonly known as
spasmodic torticollis, usually begins in adulthood. It may involve any bilateral combination of
lateral neck muscles, especially the SCM and trapezius. Characteristics of this disorder are
sustained turning, tilting, flexing, or extending of the neck. Shifting the head laterally or
anteriorly can occur involuntarily (Fahn et al., 2005). The shoulder is usually elevated and
displaced anteriorly on the side to which the chin turns.
Subclavian Vein Puncture
The right or left subclavian vein is often the point of entry to the venous system for central
line placement, such as a Swan-Ganz catheter. Central lines are inserted to administer parenteral
(venous nutritional) fluids and medications and to measure central venous pressure. In an
infraclavicular subclavian vein approach, the administrator places the thumb of one hand on the
middle part of the clavicle and the index finger on the jugular notch in the manubrium (Fig.
B8.2). The needle punctures the skin inferior to the thumb (middle of the clavicle) and is
advanced medially toward the tip of the index finger (jugular notch) until the tip enters the right
venous angle, posterior to the sternoclavicular joint. Here the internal jugular and subclavian
veins merge to form the brachiocephalic vein. If the needle is not inserted carefully, it may
puncture the pleura and lung, resulting in pneumothorax. Furthermore, if the needle is inserted
too far posteriorly, it may enter the subclavian artery. When the needle has been inserted
correctly, a soft, flexible catheter is inserted into the subclavian vein, using the needle as a guide.
Right Cardiac Catheterization
For right cardiac catheterization (to take measurements of pressures in the right chambers of
the heart), puncture of the IJV can be used to introduce a catheter through the right
brachiocephalic vein into the superior vena cava (SVC) and the right side of the heart. Although
the preferred route is through the IJV or the subclavian vein, it may be necessary in some
patients to use the EJV. This vein is not ideal for catheterization because its angle of junction
with the subclavian vein makes passage of the catheter difficult.
Prominence of External Jugular Vein
The EJV may serve as an “internal barometer.” When venous pressure is in the normal
range, the EJV is usually visible above the clavicle for only a short
distance. However, when venous pressure rises (e.g., as in heart failure), the vein is prominent
throughout its course along the side of the neck. Consequently, routine observation of the EJVs
during physical examinations may give diagnostic signs of heart failure, SVC obstruction,
enlarged supraclavicular lymph nodes, or increased intrathoracic pressure.
Severance of External Jugular Vein
If the EJV is severed along the posterior border of the SCM where it pierces the roof of the
lateral cervical region (e.g., by a knife slash), its lumen is held open by the tough investing layer
of deep cervical fascia, and the negative intrathoracic pressure air will suck air into the vein. This
action produces a churning noise in the thorax and cyanosis (a bluish discoloration of the skin
and mucous membranes resulting from an excessive concentration of reduced hemoglobin in the
A venous air embolism produced in this way will fill the right side of the heart with froth, which
nearly stops blood flow through it, resulting in dyspnea. The application of firm pressure to the
severed jugular vein until it can be sutured will stop the bleeding and entry of air into the blood.
Lesions of Spinal Accessory Nerve (CN XI)
Lesions of the spinal accessory nerve are uncommon. CN XI may be damaged by:
Penetrating trauma, such as a stab or bullet wound.
Surgical procedures in the lateral cervical region.
Tumors at the cranial base or cancerous cervical lymph nodes.
Fractures of the jugular foramen where CN XI leaves the cranium.
Although contraction of one SCM turns the head to one side, a unilateral lesion of CN XI usually
does not produce an abnormal position of the head. However, people with CN XI damage
usually have weakness in turning the head to the opposite side against resistance. Lesions of the
CN XI produce weakness and atrophy of the trapezius, impairing neck movements.
Unilateral paralysis of the trapezius is evident by the patient's inability to elevate and retract the
shoulder and by difficulty in elevating the upper limb superior to the horizontal level. The
normal prominence in the neck produced by the trapezius is also reduced. Drooping of the
shoulder is an obvious sign of CN XI injury. During extensive surgical dissections in the lateral
cervical region—for example, during removal of cancerous lymph nodes—the surgeon isolates
CN XI to preserve it, if possible. An awareness of the superficial location of this nerve during
superficial procedures in the lateral cervical region is important because CN XI is the most
commonly iatrogenic nerve injury (G. iatros, physician or surgeon).
Severance of Phrenic Nerve, Phrenic Nerve Block, and Phrenic Nerve Crush
Severance of a phrenic nerve results in paralysis of the corresponding half of the diaphragm
(see the blue box “Paralysis of the Diaphragm” on p. 85). A phrenic nerve block produces a short
period of paralysis of the diaphragm on one side (e.g., for a lung operation). The anesthetic is
injected around the nerve where it lies on the anterior surface of the middle third of the anterior
scalene muscle. A surgical phrenic nerve crush (e.g., compressing the nerve injuriously with
forceps) produces a longer period of paralysis (sometimes for weeks after surgical repair of a
diaphragmatic hernia). If an accessory phrenic nerve is present, it must also be crushed to
produce complete paralysis of the hemidiaphragm.
Nerve Blocks in Lateral Cervical Region
For regional anesthesia before neck surgery, a cervical plexus block inhibits nerve impulse
conduction. The anesthetic agent is injected at several points along the posterior border of the
SCM, mainly at the junction of its superior and middle thirds, the nerve point of the neck (Figs.
8.8 and 8.13A). Because the phrenic nerve supplying half the diaphragm is usually paralyzed by
a cervical nerve block, this procedure is not performed on persons with pulmonary or cardiac
disease. For anesthesia of the upper limb, the anesthetic agent in a supraclavicular brachial
plexus block is injected around the supraclavicular part of the brachial plexus. The main
injection site is superior to the midpoint of the clavicle.
Injury to Suprascapular Nerve
The suprascapular nerve is vulnerable to injury in fractures of the middle third of the
clavicle. Injury of this nerve results in loss of lateral rotation of the humerus at the glenohumeral
joint. Consequently the relaxed limb rotates medially into the waiter's tip position (see Fig.
B6.12B). The ability to initiate abduction of the limb is also affected.
Ligation of External Carotid Artery
Ligation of an external carotid artery is sometimes necessary to control bleeding from one
of its relatively inaccessible branches. This procedure decreases blood flow through the artery
and its branches but does not eliminate it. Blood flows in a retrograde (backward) direction into
the artery from the external carotid artery on the other side through communications between its
branches (e.g., those in the face and scalp) and across the midline. When the external carotid or
subclavian arteries are ligated, the descending branch of the occipital artery provides the main
collateral circulation, anastomosing with the vertebral and deep cervical arteries.
Surgical Dissection of Carotid Triangle
The carotid triangle provides an important surgical approach to the carotid system of
arteries. It also provides access to the IJV, the vagus and hypoglossal nerves, and the cervical
sympathetic trunk. Damage or compression of the vagus and/or recurrent laryngeal nerves during
surgical dissection of the carotid triangle may produce an alteration in the voice because these
nerves supply laryngeal muscles.
Carotid Occlusion and Endarterectomy
Atherosclerotic thickening of the intima of the internal carotid artery may obstruct blood
flow. Symptoms resulting from this obstruction depend on the degree of obstruction and the
amount of collateral blood flow to the brain and structures in the orbit from other arteries. A
partial occlusion of the internal carotid may cause a transient ischemic attack (TIA), a sudden
focal loss of neurological function (e.g., dizziness and disorientation) that disappears within 24
hr. Arterial occlusion may also cause a minor stroke, a loss of neurological function such as
weakness or sensory loss on one side of the body that exceeds 24 hr but disappears within 3
Obstruction of blood flow can be observed in a Doppler color study (Fig. B8.3A). A Doppler is a
diagnostic instrument that emits an ultrasonic beam and detects its reflection from moving fluid
(blood) in a manner that distinguishes the fluid from the static surrounding tissue, providing
information about its pressure, velocity, and turbulence. Carotid occlusion, causing stenosis
(narrowing) in otherwise healthy persons (Fig. B8.3B) can be relieved by opening the artery at
its origin and stripping off the atherosclerotic plaque with the intima. This procedure is called
carotid endarterectomy. After the operation, drugs that inhibit clot formation are administered
until the endothelium has regrown. Because of the relations of the internal carotid artery, there is
risk of cranial nerve injury during the procedure involving one or more of the following nerves:
CN IX, CN X (or its branch, the superior laryngeal nerve), CN XI, or CN XII (Fig. 8.21).
Carotid Pulse
The carotid pulse (“neck pulse”) is easily felt by palpating the common carotid artery in the
side of the neck, where it lies in a groove between the trachea and the infrahyoid muscles. It is
usually easily palpated just deep to the anterior border of the SCM at the level of the superior
border of the thyroid cartilage. It is routinely checked during cardiopulmonary resuscitation
(CPR). Absence of a carotid pulse indicates cardiac arrest.
Carotid Sinus Hypersensitivity
In people with carotid sinus hypersensitivity (exceptional responsiveness of the carotid
sinuses in various types of vascular disease), external pressure on the carotid artery may cause
slowing of the heart rate, a fall in blood pressure, and cardiac ischemia resulting in fainting
(syncope). In all forms of syncope, symptoms result from a sudden and critical decrease in
cerebral perfusion (Hirsch et al, 2005). Consequently, this method of checking the pulse is not
recommended for people with cardiac or vascular disease. Alternate sites, such as the radial
artery at the wrist, should be used to check pulse rate in people with carotid sinus
Role of Carotid Bodies
The carotid bodies are in an ideal position to monitor the oxygen content of the blood before
it reaches the brain. A decrease in PO2 (partial pressure of oxygen), as occurs at high altitudes or
in pulmonary disease, activates the aortic and carotid chemoreceptors, increasing alveolar
ventilation. The carotid bodies also respond to increased carbon dioxide (CO2) tension or free
hydrogen ions in the blood. The glossopharyngeal nerve (CN IX, perhaps with involvement of
the vagus nerve) conducts the information centrally, resulting in reflexive stimulation of the
respiratory centers of the brain that increase the depth and rate of breathing. The pulse rate and
blood pressure also increase. With the increased ventilation and circulation, more oxygen is
taken in and the concentration of CO2 is reduced accordingly.
Internal Jugular Pulse
Although pulsations are most commonly associated with arteries, pulsations of the internal
jugular vein can provide information about heart activity corresponding to electrocardiogram
(ECG) recordings and right atrial pressure. The IJV pulse is not palpable in the same manner as
arterial pulses; however, the vein's pulsations are transmitted through the surrounding tissue and
may be observed beneath the SCM superior to the medial end of the clavicle.
Because there are no valves in the brachiocephalic vein or the superior vena cava, a wave of
contraction passes up these vessels to the inferior bulb of the IJV. The pulsations are especially
visible when the person's head is inferior to the lower limbs (the Trendelenburg position). The
internal jugular pulse increases considerably in conditions such as mitral valve disease (see
Chapter 1), which increases pressure in the pulmonary circulation and the right side of the heart.
The right IJV runs a straighter, more direct course to the right atrium than does the left; thus it is
the one that is examined (Swartz, 2006).
Internal Jugular Vein Puncture
A needle and catheter may be inserted into the IJV for diagnostic or therapeutic purposes.
The right internal jugular is preferable because it is usually larger and straighter. During this
procedure, the clinician palpates the common carotid artery and inserts the needle into the IJV
just lateral to it at a 30° angle, aiming at the apex of the triangle between the sternal and the
clavicular heads of the SCM, the lesser supraclavicular fossa (Fig. B8.4). The needle is then
directed inferolaterally toward the ipsilateral nipple.
The Bottom Line
Sternocleidomastoid and trapezius: The SCM and trapezius muscles share their origins from a
common embryologic source, innervation by the spinal accessory nerve (CN XI), enclosure by
the investing layer of deep cervical fascia, a linear superior attachment to the cranial base, and an
inferior attachment to the pectoral girdle. ♦ Their superficial masses and palpable borders
provide the basis for describing the regions of the neck. ♦ The SCM produces multiple
movements of the head and neck. ♦ The trapezius causes multiple movements of the scapula,
depending on whether the muscles act unilaterally or bilaterally and independently or in
conjunction with concentric or eccentric contraction of other muscles.
Lateral cervical region: The lateral cervical region is bounded by the SCM, trapezius, and middle
third of the clavicle, with a muscular floor formed by the lateral deep cervical muscles. ♦ It is
subdivided by the diagonally placed inferior belly of the omohyoid. ♦ Most apparent within the
superior occipital triangle is the lower half of the external jugular vein. ♦ Most important
clinically is the superficially located spinal accessory nerve (CN XI). ♦ In the inferior and much
smaller omoclavicular triangle, the brachial plexus emerges between the middle and anterior
scalene muscles, the latter of which is crossed anteriorly by the phrenic nerve. ♦ Superior to the
brachial plexus, and in the same plane, is the cervical plexus. ♦ The cutaneous branches of this
plexus emerge from the midpoint of the posterior border of the SCM and radiate toward the
scalp, auricle, anterior neck, and shoulder.
Anterior cervical region: The anterior cervical region is inferior to the body of the mandible,
extending anteriorly from the SCM to the midline. ♦ The bellies of the digastric, the anterior
belly of the omohyoid, and the hyoid subdivide the region into smaller triangles. ♦ The
submental triangle is superficial to the floor of the mouth. ♦ The submandibular triangle, superior
to the digastric bellies, is occupied by the submandibular salivary gland and submandibular
lymph nodes. ♦ The facial artery, coursing within this triangle, is palpable as it emerges from it
and crosses the body of the mandible. ♦ The carotid triangle, between the posterior belly of the
digastric, inferior belly of the omohyoid, and SCM, includes much of the carotid sheath and
related structures, including the bifurcation of the common carotid, the carotid sinus and body,
and the initial branches of the external carotid artery. ♦ The muscular triangle is formed and
occupied by the infrahyoid muscles.