Int J Anat Res 2015, 3(3):1302-05. ISSN 2321-4287 1302 Case Report
UNILATERAL ABSENCE OF THE STERNOHYOID M USCLE W ITH
CONTRALATERAL TENDINOUS BELLY OF SUPERIOR BELLY OF
OM OHYOID M USCLE: A VERY RARE FORM OF INFRAHYOID
M USCLE VARIATION
Prabhas Ranjan Tripathy *
1, Chappity. Preetam
2.
ABSTRACT
Address for Correspondence: Dr. Prabhas Ranjan Tripat hy, Assistant Professor, Depart ment of Anat omy, All India Instit ute of M edical sciences, Bhubaneswar, Odisha, India. M ob. +919861187082
E-M ail: prabhas_ranju@yahoo.co.in
* 1 Assistant Professor, Depart ment of Anatomy, All India Instit ute of M edical sciences, Bhubaneswar,
Odisha, India.
2 Assist ant Professor, Depar t m ent of ENT & HNS, All India Inst it ut e of M edical sciences,
Bhubaneswar, Odisha, India.
The st ernohyoid, st ernot hyr oid, t hyrohyid and om ohyoid const it ut e t he infrahyoid group of ant erior n eck m uscles. All t hese m uscles are supplied by Ansa crvicalis relat ed t o t he ant erior w all of carot id sheat h. Dur ing regular cadaver ic dissect ion in t he Depar t m ent of Anat om y at AIIM S, Bhubanesw ar, a case of r ight sid ed absence of st ernohyoid m uscle w it h left sided t endinous superior belly of om ohyoid m uscle w as found. Though lit erat ure survey show s t he t endinous belly (or absence) of super ior belly of om ohyoid m uscle, but it s presence in com binat ion w it h absence of opposit e side st ernohyoid m uscle is hardly repor t ed. The om ohyoid m uscle has eff ect on int racerebral venous hem odynam ics. Developing from a com m on m uscle pr im odium t he infrahyoid m uscle group show s a num ber of variat ions. Because of increased use of Infrahyoid m yocut aneous f laps for m edium sized head and neck reconst ruct ion surgery t his know ledge w ill be helpful for handling and select ing a flap.
KEY W ORDS:Inf rahyoid, St ernohyoid, Om ohyoid M uscles, Infrahyoid M yocut aneous Flap.
INTRODUCTION
Int ernat ional Journal of Anatomy and Research, Int J Anat Res 2015, Vol 3(3):1302-05. ISSN 2321- 4287 DOI: ht t p:/ / dx.doi.org/10.16965/ ijar.2015.216
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Received: 15 Jul 2015 Accept ed: 13 Aug 2015 Peer Review : 15 Jul 2015 Published (O): 31 Aug 2015 Revised: None Published (P): 30 Sep 2015
Int ernat ional Journal of Anat omy and Research ISSN 2321-4287
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DOI: 10.16965/ ijar.2015.216
The infrahyoid m uscles include st ernohyoid, st ernothyroid, thyrohyoid and omohyoid muscle. The st ernohyoid and omohyoid lie superficially and t he st ernot hyroid and omohyoid lie in deep st rat a. They are innervat ed by ansa cervicalis. These muscles are involved in t he process of vocalizat ion, sw allow ing and m ast icat ion [1]. Various form s of anomalies are report ed for t heses m uscles and due t o t he degenerat ing nat ur e t he om ohyoid m uscle show s a high degree of variat ions [2].
CASE REPORT
Int J Anat Res 2015, 3(3):1302-05. ISSN 2321-4287 1303 Prabhas Ranjan Tr ipat hy, Chappit y. Pr eet am. UNILATERAL ABSENCE OF THE STERNOHYOID M USCLE W ITH CONTRALATERAL TENDINOUS
BELLY OF SUPERIOR BELLY OF OM OHYOID M USCLE: A VERY RARE FORM OF INFRAHYOID M USCLE VARIATION.
inferior belly of omohyoid and st ernot hyroid muscle, as t he st ernohyoid muscle w as absent in t his case. The superior belly of om ohyoid appeared t oo t hickened in t his case. On left side t he st ernohyoid m uscle w as pr esent in t he m uscular t riangle, but t he super ior belly of omohyoid appeared as a t endinous struct ure. On bot h sides the inferior belly of omohyoid muscle w as normal in appearance.
Phot o 1: Show ing right side neck w it h right side absent
st ernohyoid m uscle w it h st ernot hyroid and t hyrohyoid m uscle.
I-OM (Inferior belly of Om ohyoid M .), S-OM (Super ior belly of Om ohyoid M .), STT (St ernot hyroid M .), SCLM (St ernocleidom ast oid M .), TH (Thyrohyoid M .)
Photo 2: Show ing left side neck w it h t endinous superior
belly of om ohyoid m uscle and pr esence of st er nohyoid m uscle
I-OM (Inferior belly of Om ohyoid M .), S-OM (Super ior belly of Om ohyoid M .), , SCLM (St ernocleidom ast oid M .), STH (St ernohyoid M .).
Phot o 3: Right side neck w it h st er nocleidom ast oid
(SCLM ) m uscle is cut and reflect ed and t w o bellies of om ohyoid(S-OM & I-OM ) ar e separ at ed t o show t he branches from loop of ansa cervicalis.
IJV-Int ernal Jugular Vein, CCA-Com m on Carot id Art ery, 1-Superior Root of Ansa cervicalis (Desendens Hypoglossi),2 -Loop of Ansa cervicalis 3- Inferior Root of Ansa cervicalis 4-Hypoglossal Nerve 5-Nerve t o Geniohyoid m uscle, 6- Nerve t o Thyrohyoid m uscle, 7-Branch t o Super ior belly of Om ohyoid m uscle, 8-Branch t o St ernot hyroid m uscle, 9-Branch t o Inf erior belly of Om ohyoid m uscle.
The t w o bellies of Omohyoid muscle divides t he ant erior and post erior t riangles of neck int o a n u m b er o f su b t r i angl es an d p o r t r aysan import ant land mark for many neck st ruct ures. Case report s and st udies pert aining t o variat ion in morphology of omohyoid muscle have been r eport ed. Anom alies can be r elat ed t o t he pr esence or absence of bellies, or igin and in ser t i on , n o of belli es and it s p r o xim it y/ at t achment t o ot her infrahyoid muscles. Some o f t h e r epo r t ed ano m ali es ar e u n u su al at t achment of S-OM t o t ransverse process of C6 vert ebra [3], absent inferior belly of OM w it h t he super ior belly at t ached t o clavicle [ 4],
d u pl i cat ed su p er i o r b ell y of t he OM [5] ,
unilateral duplicated superior and inferior
bellies [6] duplicat ed Omohyoid and appearance of t he Levat or Glandulae Thyroideae M uscles [7], t riplicat ion of superior belly and insert ion of superior belly t o t he t hyroid cart ilage [8], norm al omohyoid muscle w it h a cleido-hyoid at t achment [9] and absence of muscular part of t he superior belly of the omohyoid w ith a fibrous t endon [10,11,27] as in our case.
In t he st udy by Rajlaxmi Rai et al [2] regarding t he anat om ic variat ion of Om ohyoid muscle, apart from normal superior and inferior belly at t achment in 85% cases 4 ot her variet ies i.e. Type I Double om ohyoid (superior & inferior omohyoid) 3%,Type II Cleido-hyoideus - Inferior belly from clavicle & superior belly at t ached t o hyoid bone6%, Type III Short OH - Inferior belly from clavicle & superior belly m erging w it h Sternohyoid3%, Type IV Superior belly receiving Slips from st ernum w it h normal inferior belly 3% have been report ed.
Fou r t y pes o f in t er m edi at e m o r ph ol ogies bet w een normal and anomalous morphologies of t he superior belly of t he omohyoid muscle observed by Sukekawa Ret al [12] are t ype 1 with unclear anterior margin of t he superior belly due t o t he poor m yof iber developm ent ; in
Int J Anat Res 2015, 3(3):1302-05. ISSN 2321-4287 1304 Prabhas Ranjan Tr ipat hy, Chappit y. Pr eet am. UNILATERAL ABSENCE OF THE STERNOHYOID M USCLE W ITH CONTRALATERAL TENDINOUS
BELLY OF SUPERIOR BELLY OF OM OHYOID M USCLE: A VERY RARE FORM OF INFRAHYOID M USCLE VARIATION.
Surgical Significance: The com m only used pedicled myocut aneous flaps for head and neck reconst ruct ion are pect oralis major, t rapezius, lat issim us dor si et c. The use of inf r ahyoid myocut aneous (IHM C) flaps for reconst ruct ing head and neck surgical defect s is w ell accept ed. Wang [17] is considered t o be t he fat her of t his flap surgery, t hough t he concept of infrahyoid f lap w as f i r st gi ven by Clai r m o n t an d Conley(1977) [18]. The IHF free flaps is used in t he m anagem ent of m edium sized def ect s (average size being 7×4 cm) of the floor of mout h, alveolar r idge, and base of t ongue [ 19]. It includes t he st ernohyoid, st ernot hyroid and omohyoid muscle muscles and t he skin paddle overlying it . They get a segment al supply from Sup er io r an d in f er i o r t h y r o i d ar t er y an d perforat ors of t he infrahyoid muscles(20). They can be used for muscle reconstruction, t reatment of bowed vocal-cord and laryngeal repair, surgery for oropharyngeal cancer [21] et c. Pr evious t hyroid surgery or neck dissect ion, N3 neck m et ast asis, previous irradiat ion and posit ive lymph nodes at level III–IV are some limit at ions in select ing t he f laps [19] . Though t he f lap raises doubt s over adherence t o oncological principles, it s use in a N0 neck, radiologcally proven neck is invaluable. The omohyoid muscle serves as a reliable landmark for t he radical neck dissect ion and endoscopic explorat ion of t he brachial plexus [22, 23]. It is also t he surgical l an d m ar k f or lev el III an d IV l ym p h n od e met ast ases [24].
M orphological Significance: Developing from a muscle primordium in the anterior cervical area t he infrahyoid muscles [25] are first divided int o a shallow layer and a deep layer. The deep layer becom es t he st er not hyoid and t hyr ohyoid m u scl es. The shal l ow l ay er b ecom es t h e splenius spr ead in t he cer vical r egion, t he i n t er m ed i at e p ar t of w h ich in h um an s i s degenerat ed and t he splenius is separat ed int o t he int ernal and ext ernal muscles. The int ernal muscle becomes t he sternohyoid muscle and t he low er part of t he ext ernal muscle becomes t he omohyoid, w hich runs obliquely in t he lat eral cervical area[25].The anomalies caused by t he omohyoid and t he sternohyoid and various forms of adhesion betw een tw o muscles represent the primit ive morphology of the splenius. It has been t ype 2, t he superior belly w as composed of a
post erior large belly and an ant erior small belly; in t ype 3, superior belly composed of t hree t o five bellies and t he bellies w ere arranged in a roof t ile-like morphology; in t ype 4, t he superior belly was found to consist of tw o bellies arranged par allel t o each ot her in ant erior -post er ior
direction as in our case.
Lot h andM i ur a et al . have al so cl assi f i ed different forms of anomalies int o five t ypes and six t ypes respect ively [13, 5].
Th ou gh t h e t ext b o ok m en t i on s t h at t h e sternohyoid muscle may be absent or double (1), lit erat ure survey show s no report about t he absence of st ernohyoid muscle and t his is t he first case t o be report ed. It s associat ion w it h op po si t e sid e t end ino us sup er io r bell y of omohyoid m uscle (claimed t o be absence of superior belly by some ot hers) is also a very rare case. In t his case t he superior belly of omohyoid muscle is supplied by t he desendens hypoglossi and t he loop of ansa cervicalis provides t w o branches i.e. t o inferior belly of omohyoid and st er not hyroid, as t he st ernohyoid m uscle is absent .
Ot her rare form infrahyoid anom aly are t he t h yr o h yo i d i s of t en co n t i n u ou s w i t h t h e st ernot hyroid, t he medial fibers on bot h sides of st ernot hyroid may form a cruciate pattern ,t he muscle m ay exist in t w o st rat a, or it may be divided longit udinally int o bundles; t he lat eral bundle may t erminat e in cervical fascia [26].
Int J Anat Res 2015, 3(3):1302-05. ISSN 2321-4287 1305
suggest ed t hat because t he human omohyoid is degenerat ing, t he incidence of anomalies is high[2]. Unusual omohyoid forms described by Ber gm an et al . ar eclei do f ascialis , cleid o-hyoideus, and hyofascialis [26].
CONCLUSION
The Head and Neck reconst ruct ive surgery is in a st age of evolut ion and t he use of Infrahyoid myocut aneous (IHM C) flap for medium size de-fect s is an emerging concept . St udy on various anomaly of infrahyoid muscles w ill help a lot in dealing w it h various surgical challenges. This case of unilat eral absence of st ernohyoid muscle w it h cont ralat eral t endinous superior belly of omohyoid muscle is t he first case to be report ed.
Conflicts of Interests: None
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Prabhas Ranjan Tr ipat hy, Chappit y. Pr eet am. UNILATERAL ABSENCE OF THE STERNOHYOID M USCLE W ITH CONTRALATERAL TENDINOUS BELLY OF SUPERIOR BELLY OF OM OHYOID M USCLE: A VERY RARE FORM OF INFRAHYOID M USCLE VARIATION.
