Illustrated Anatomy of the Head and Neck Review Question Answers With Rationale

Introduction

The sternocleidomastoid muscle (SCM) is one of more than 20 pairs of muscles that act on the neck. SCM has a dual-innervation and multiple functions. The vestibular area has a close relationship with the SCM motoneurons to meliorate posture and neck movements; the cervico-trigeminal reflexes put in direct contact the occlusive capacity of the temporomandibular joint and the electrical activity of the SCM, with a reciprocal influence, in particular with the masseter muscle. The inspiratory human activity is facilitated by the contraction of the SCM muscle.

The latter is a muscle capable of adapting to external and internal influences for which it is stressed, both for physiological stressors (hypertrophy) and for pathological stressors (change in metabolism). The commodity describes the beefcake, its innervation and vascularization, as well as the double embryological derivation. The text will highlight the clinical, surgical, and related pathologies, with a look at the SCM'due south manual therapeutic approach.

Structure and Office

The unilateral contraction of the sternocleidomastoid musculus (SCM) determines a triple movement, associating the rotation of the caput on the side opposite to that of its contraction, the inclination from the side of its wrinkle, and extension.[i]

The furnishings of the simultaneous wrinkle of the two muscles depend on the land of contraction of the other muscles of the cervical spine:

• If the cervical spine is not fixed, this bilateral contraction determines a hyperlordosis of the cervical spine with an extension of the head and a bending of the cervical spine on the dorsal ane.

• If the cervical spine is rigid and rectilinear due to the contraction of the paravertebral muscles, the simultaneous contraction of the SCM determines the flexion of the cervical spine on the dorsal spine and a flexion of the caput forward.

The SCM can also have inspiratory muscle action by taking a fixed point on the temporal bone and so lifting the sternum and the clavicles.[1]

SCM plays an important office in the posture of the neck and the body. Information technology has been shown that a stimulation of the vestibular expanse electrically activates the sternocleidomastoid with testify of a shut connection between the vestibular expanse and the motoneurons of the SCM.[2] The move with which the SCM expresses its maximum capacity for speed and strength is the lateral inclination.[iii]

Some other of import function of SCM is to allow a correct office of the temporomandibular joint (TMJ). During mastication a trigeminal-cervical reflex stimulates the activity of SCM, in that location is bear witness that SCM intervention is fundamental for optimal TMJ apoplexy.[iv] An occlusal alteration of the mandible causes an alteration of the function of the SCM, with disorders of muscular incoordination (inclinations of the neck).[4] The correction of an altered apoplexy or the treatment of a tooth has solved, in some cases, the problem of torticollis.[4]  During mastication on one side, the activity of the SCM is synchronous with the masseter musculus, while with bilateral chewing the SCM anticipates the intervention of the masseter, probably to stabilize the neck.[4]

Anatomy

The sternocleidomastoid muscle (SCM) divides the neck expanse into an anterior triangle and a posterior triangle. The inductive triangle is delimited by the posterior border of the SCM, the inferior border of the mandible inferiorly, and the medial line of the neck, medially.[one] In the anterior triangle, nosotros find the suprahyoid and infrahyoid muscles. The posterior triangle is delimited by the SCM anteriorly, by the clavicle inferiorly, and by the trapezius muscle posteriorly. Scalene muscles reside in the posterior triangle. The SCM is a large and easily recognizable and palpable muscle.[1]

SCM tin can be divided into four portions:

• Sterno-mastoid

• Sterno-occipital

• Cleido-mastoid

• Cleido-occipital

The muscle originates from the upper edge of the sternal manubrium, from the medial quarter of the upper confront of the clavicle; the two muscle heads merge into a single muscle belly that is directed upwards and laterally. Insertions arrive at the mastoid process of the temporal bone and at the anterior portion of the superior nuchal line.[v] SCM has fibers arranged in parallel; it is not a pennate musculus.[5] SCM expresses greater strength and thickness in men than women; the sterno-mastoid portion is the muscle area that develops a greater percentage of contractile strength than the other portions. The cleido-occipital portion is the muscular area where less force develops.[v]

Embryology

SCM derives from paraxial mesoderm (preoptic) and occipital (postotic) somites; in office, it as well derives from the neural crests.[6][7] On an animal model, the SCM musculus appears on the 14th day of gestation. Co-ordinate to a recent written report, cells that will form the muscles of the cervix share space with the progenitor cells of the heart, within the cardiopharyngeal mesoderm.[8]

Blood Supply and Lymphatics

The arterial supply is given by branches of the external carotid artery (occipital artery and superior thyroid artery), which tin can exist palpated, feeling the heartbeat in the medial-inductive portion of the musculus. During intense concrete activeness, the blood supply to the respiratory muscles increases, including the CSM, to the detriment of the muscles of the limbs.[nine]

The external jugular vein passes inferiorly and posteriorly the SCM, from which it drains venous blood (external posterior jugular vein and anterior jugular vein).[1]

The lymphatic system of the neck that involves the SCM is the vertical chain, which includes the anterior superficial lymph nodes and the lymph nodes of the posterior triangle (inferiorly).[1]

Nerves

The cutaneous branches of the cervical plexus emerge from the posterior edge of the SCM; these nervus endings help the muscle in its proprioceptive functions. The accessory cranial nerve or Eleven passes into the posterior triangle to innervate the trapezius and the SCM.[1]

Muscles

The muscles that make up the neck are office of the myofascial system, which determines not only an anatomical just as well a functional continuum.[10] This means that a dysfunction of a muscular portion will outcome in a functional alteration of all the muscles of the neck. For instance, an centre disorder alters the electromyographic spectrum of the masseter muscle and neck muscles, including SCM.[11][12]

The neck muscles (superficial and deep) are activated by the cortical system via the reticulo-spinal organisation; activation is synchronous, regardless of the depth of the muscle layer.[13] A further starting point to understand is that it is a mistake to consider a therapeutic problem that plain presents itself to a single muscular district. In fact, the whole neck muscle complex is negatively affected, and information technology must be taken into account for the achievement of a successful clinical event.

The sternocleidomastoid muscle in healthy subjects is rich in white or anaerobic fibers (well-nigh 65%), with a lower percentage of red or aerobic fibers (about 35%).[14] The muscle is able to express a lot of force quickly, with less resistance over prolonged periods. In older people, the percentage of white and red fibers in the SCM changes. Red fibers tend to increase (about 44% in full) to the detriment of white fibers.[15] The muscle adapts itself to the surrounding surround and to onetime historic period, adapting specularly.

Physiologic Variants

As with the entire anatomy of the man body, the sternocleidomastoid musculus (SCM) also has anatomical abnormalities.

SCM could present a built unilateral agenesis, including the unilateral absenteeism of the trapezius muscle, without meaning functional repercussions, probably due to adaptations of the other musculus groups that make upward the cervix.[sixteen]

Other variations include its origin, which variations can make the difference in the surgery. The attachment to the clavicle could be narrow or wide (about 7 to viii centimeters), or have more than 1 clavicular attachment; the attack could also affect the acromion-clavicular joint or present more muscular bellies of the SCM.[17] It is possible to detect insertions to the sternoclavicular joint, changing the beefcake of the neck and the palpatory result.[17]

A larger number of SCM muscle heads is not then rare; for example, you tin can discover two sternomastoid, a cleido-occipital and a cleido-mastoid occipital on one side, while on the other side a single sternomastoid, a cleido-occipital and two cleido-mastoids, with a total of four muscle heads.[17],[xviii]

Rarely, the margin of SCM can be in directly contact with the trapezius, probably due to embryological motivations.[19] Other changes concern its insertions. Nosotros can find a cleido-epistrophic, cleido-cervical and cleido-atlantic insertions, with i or more heads on the os attack.[19]

The innervation affecting the SCM may vary. One study reports the innervation of the lower portion of SCM from a branch of C1 from the ansa cervicalis (descendens hypoglossi); the same can happen only for the upper portion of the muscle.[twenty] An aberrant co-operative of the facial nerve has been constitute to innervate the deep portion of the upper third of the SCM.[21]

The variations of SCM can besides be found in the names with which it is known: nutator capitis, mastoideus colli, sternocleidomastoid muscle of Kopfnicker, and sternomastoid muscle.[19]

The reflection of all these anatomical variables is to take caution earlier budgeted with therapeutic intention because an abnormal behavior of the musculus does not necessarily mean pathology. Not only that, information technology must be remembered that anatomy is always subjective and that anatomy of study books does non always reverberate subjectivity.

Surgical Considerations

The sternocleidomastoid muscle (SCM) is often used for the repair of other parts of the body.

A flap of SCM can be used for the resection of the parotid gland, in the example of tumors. The musculus makes it simpler to obtain an acceptable length and a rotation of the flap on the incision surface area during the intervention, decreases the depression of the parotidectomy area, and lowers the take a chance of necrosis thanks to the rich vascularization of SCM. [22] Currently, at that place is no accented rubber for the prevention of Frey's syndrome (auriculotemporal nerve injury).[22]

SCM is used for many other situations where it is necessary to repair or reconstruct the orofacial and pharyngeal area. Some muscular flaps or the latter with bony portions are used, depending on the surgical objective.[23] Examples of reconstructive intervention are:

• Reconstruction of the tongue and/or buccal flooring

• Oral cavity and/or oropharynx, laryngotracheal circuitous

• Portions of the head and/or cervix

• Os of the jaw, defects of the mastoid area

• Esophagopharyngeal complex

• Reconstruction of the cheek

Another surgical area where SCM muscle flaps are used is in the presence of congenital muscular torticollis (MT), although the cause is not entirely understood. When SCM is shortened and fibrotic (MT) it affects the position of the head and shoulder, ipsilateral lateral flexion, a contralateral rotation of the child'south face.[24] With this disorder, there are two options to follow, based on the doctor's evaluation: rehabilitation or surgery. If too much fourth dimension is passed from the diagnosis and no blazon of therapeutic intervention is performed, in the shortening SCM a ring of strong musculus is formed, or in severe cases, MT persists, causing deformity of the craniofacial morphology.[24] Within the child's five years of age, adept results can withal be achieved, only it is better to work early.[25] In the cases where an developed has an untreated built strong neck, the surgeon'due south goal is to release the rigid band of the SCM; the upshot is never comparable to a infant, merely some facial and cervical deformities can improve.[24]

Clinical Significance

Sternocleidomastoid Musculus Function Evaluation

The assessment begins with a patient sitting to observe whatever hypotrophy of sternocleidomastoid muscle (SCM) as well every bit postural abnormalities of the neck and head, shoulder and scapula, clavicle, and sternal manubrium.

The patient is asked to perform some voluntary actions with the cervix to empathize if in that location are motor or pain limitations and perform a forced inhalation and mimic chewing to observe how the SCM behaves.

The reflexes are evaluated by hitting with a small hammer the insertion of the SCM at the clavicular level. To evaluate the strength, always with the patient seated, he is asked to move his head (flexion, rotation and inclination), putting our hand on his head at the same time to employ a minimum of resistance.

The lesions that tin affect the SCM tin touch on the accessory nerve, but they are infrequent as a finding. [26] A lesion of the XI nervus causes the reflex to be removed with the hammer, with cloudburst of the SCM and trapezius, a lowering of the shoulder and the appearance of the sign of Sicard (increase in the depth of the supraclavicular fossa). Paralysis of SCM can crusade a course of torticollis.

There are different types of torticollis: [27]

• Paralytic torticollis (from injury of the cranial nervus XI)

• Congenital torticollis

  • this condition is often seen in association with other intrauterine packaging (IUP) disorders

  • other notable IUP atmospheric condition include: metatarsus adductus (MA)[28], developmental dysplasia of the hip (DDH) [29], acetabular dysplasia, and congenital hip dislocations

  • congenital torticollis can exist seen in association with MA most xv% of the time [thirty]

• Spasmodic torticollis (a phenomenon of segmental dystonia)

• Ocular torticollis, where diplopia influences the posture of the SCM

• Symptomatic torticollis (the causes may be different, such as pain, inflammation, infection or cervical vertebral positioning)

• "Psychic pillow" is a position of patients with serious neurological diseases (Parkinson'south, catatonic disorders), where they keep their caput bent frontward equally if they were resting on a pillow, even when lying on their backs

• Psychogenic torticollis where the patient is agape of moving his cervix correctly to avoid the onset of pain or vertigo symptoms

The precise diagnosis of these disorders must follow an electromyographic examination, magnetic resonance or computed tomography, ultrasonography.

The surgical arroyo generally performed in children and adults is to remove part of the SCM. [31]

• Unipolar or bipolar release

• Release of the fibrous band

• Release with a Z-plasty or Z-plasty alone cut

• Release with endoscopy (less invasive)

• Muscular resection of some of his insertions

Other Bug

Manual Arroyo: Physiotherapy

When a sternocleidomastoid musculus (SCM) dysfunction needs to be addressed, all the superficial and deep muscular layers must be considered.

In the case of congenital torticollis, which represents a third of congenital muscular abnormalities, physiotherapy plays an important part in solving the dysfunction or accelerating recovery afterward a possible surgery. Recommended conservative therapy includes stretching exercises, voluntary movements to improve posture (if the kid is not too modest), or placements in the child's posture made by the parents.[24]

Fortunately, the problem is solved in many cases. [31][32] Congenital torticollis may appear not just after nativity simply also afterwards a few weeks, making parental vigilance becomes crucial. [32]

Physiotherapy is called into question not only because of the SCM trouble due to the presence of torticollis but also as a result of surgical interventions of the muscle itself. There may be some pathologies that demand a surgical approach such equally the following:

• Intramuscular hemangioma

• Pseudosarcomatous proliferative myositis (when necessary)

• Pseudotumor of infancy (fibromatosis colli)

• Rupture of the sternocleidomastoid

Other physiotherapy interventions concern the dysfunction of the neck or jaw movements post-obit whiplash impact, chronic cervical pain, headache of neurogenic origin, and trigger points.[five] The goal is always to restore proper proprioception, consummate movement without pain, and allow the disappearance of headaches. The approaches to SCM may exist dissimilar, depending on the therapist's assessment and the medical indication.

Recent studies show that SCM has greater electrical activity in patients with chronic neck pain than in subjects without chronic pain. Adding stretching and massage to classic physiotherapy appears to exist a useful strategy for patients with this clinical situation. [33] In patients (female) suffering from chronic cervical pain they demonstrate a greater infiltration of fat within the SCM, compared to subjects without pain.[34]

Alterations of the electromyographic spectrum of the SCM are linked to the presence of temporomandibular disorders, and this evaluation approach can be a tool to verify the presence of mandibular dysfunctions. [35]

Osteopathy and Manual Therapy

Osteopathic treatment to assistance the recovery of SCM after surgery should likewise affect the scar. With gentle and not-invasive techniques, the osteopathic bear upon tin can have intendance of all myofascial layers of the neck and of the spaces between the neck vertebrae.[36][37][38]

Review Questions

Figure

Anterior Triangle, M. Mylohyoideus, Mandibula, Grand. Digastricus, Submental Triangle, Submandibular Triangle, Carotid Triangle, Muscular Triangle, M. Omohyoideus (venter superior), M. Sternocleidomastoideus, Processus Mastoideus, OS Hyoideum, Yard. Scalenus (more...)

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