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Left Lateral Deep Neck, Pharyngeal Wall, and Skull Base Dissection

Surgical Correlation


Left lateral deep neck, pharyngeal wall, and skull base dissection. The ramus of the mandible and zygomatic arch have been removed along with the pterygoid muscles to provide a view of the lateral pharyngeal wall and skull base. The lateral pterygoid plate is exposed. The tensor veli palatini muscle descends along the lateral surface of the medial pterygoid plate and the tendon of this muscle passes around its bony hamulus enroute to the soft palate. Just deep and slightly posterior to the tensor muscle is the levator veli palatini, which also inserts into the soft palate. It is overlapped inferiorly by the upper border of the superior pharyngeal constrictor muscle (partially cut). Overlying this portion of the constrictor muscle are the ascending palatine branch of the facial artery and the ascending pharyngeal artery, a medial branch of the external carotid. The mandibular nerve gives rise to several branches, including the inferior alveolar nerve to the lower jaw, the lingual nerve to the tongue, buccal nerve to the skin and mucous membrane of the cheek, deep temporals, and auriculotemporal nerve whose roots enclose the middle meningeal artery. The styloid process gives rise to three muscles: stylohyoid, styloglossus, and stylopharyngeus. The internal jugular vein is seen descending in the neck and is crossed proximally by the spinal accessory nerve to the sternocleidomastoid and trapezius muscles. Deep to the vein superiorly the internal carotid artery is exposed, however, inferiorly the artery is enclosed by the carotid sheath. The external carotid artery emerges from the carotid sheath and has given off several arterial branches, including superior thyroid, ascending pharyngeal, facial, occipital, maxillary, and superficial temporal.  The hypoglossal nerve is shown descending in the neck and bending forward along the superficial surface of the hyoglossus muscle before passing deep to the mylohyoid muscle to enter the floor of the mouth. C1 fibers enclosed in the epineurium leave the hypoglossal nerve as the superior root of the ansa cervicalis to supply strap (infrahyoid) muscles.  Posterior to the internal jugular vein and deep within the neck portions of the suboccipital muscles, obliquus capitis inferior and obliquus capitis superior, are in view. (Image courtesy of AL Rhoton, Jr.)