Anatomy clinical correlates: Vessels, nerves and lymphatics of the neck

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Anatomy clinical correlates: Vessels, nerves and lymphatics of the neck

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A 12-year-old boy is currently undergoing an adenotonsillectomy secondary to sleep-disordered breathing and recurrent tonsillitis. Intraoperatively, brisk bleeding is noted from the lateral pharyngeal wall after removing the right palatine tonsil. Attempts at cauterization and hemostasis are unsuccessful with continued pulsatile bleeding. The patient’s current vital signs are temperature is 37 C° (98.6 F°), respirations are 18/minute, pulse is 116/minute, and blood pressure is 90/65 mmHg. Which of the following structures was most likely injured intraoperatively?  


The neck is a compact tube, containing many vital structures such as muscles, blood vessels, nerves, and lymphatics, as well as organs of the digestive and the respiratory tract. Now, the neck is like a sheath around these structures - however, it’s still an area prone to various injuries and conditions.

First of all, let’s discuss central venous access, which is when a catheter is placed in a large vein, usually the internal jugular or the subclavian vein. A central access is usually obtained when peripheral access isn’t available, like when an individual is severely hypovolemic, for example. If a patient will need intravenous access for a long period of time for medication delivery, such as chemotherapy, then central venous access is a great option to prevent repeated peripheral IV procedures or for those certain intravenous drugs that cause damage to peripheral veins. It can be used for fluid resuscitation, blood transfusions, central venous pressure monitoring, giving medications, hemodynamic monitoring or plasmapheresis. It can also be used when emergency dialysis is needed.

So first, let’s see how we go about accessing the internal jugular vein for central access. In order to better see the anatomy and maximize the internal jugular vein’s diameter, the individual should be in Trendelenburg position, which means that their head is down at about 15 degrees compared to the rest of the body. If the catheter is placed in the right internal jugular, then the head must be turned towards the left and vice-versa. Usually, for a catheter, the right internal jugular vein is preferred, because it has a more direct path towards the superior vena cava.


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