Head & NeckDeep Neck Spaces

Mohamed Zaitoun

Assistant Lecturer-Diagnostic Radiology Department , Zagazig University Hospitals

EgyptFINR (Fellowship of Interventional

Neuroradiology)-Switzerlandzaitoun82@gmail.com

Knowing as much as possible about your enemy precedes successful battle

and learning about the disease process precedes successful management

Deep Neck Spaces1-Anterior Visceral Space2-Carotid Space3-Retropharyngeal Space4-Posterior Cervical Space5-Perivertebral Space

1-Visceral space :-Central compartment containingseveral viscera like the larynx,thyroid, hypopharynx and cervicalesophagus2-Carotid space :-Paired space just lateral to the visceralcompartment which contains the internalcarotid artery, internal jugular vein andseveral neural structures3-Retropharyngeal space :-A small virtual space containing only fatcontinuous with the suprahyoid space andthe middle mediastinum4-Posterior Cervical Space :-Paired space posterolateral to the carotidspace-It contains fat, lymph nodes and neuralelements5-Perivertebral space :-This large space completelyencircles the vertebral body includingthe pre- and paravertebral muscles

1-Anterior Visceral Space :a) Extension :From the hyoid to the anterior mediastinum

& doesn’t extend into the suprahyoid space

b) Contents :1-Larynx (Laryngocele, SCC & Chondrosarcoma) 2-Hypopharynx / Esophagus (Zenker’s

diverticulum & SCC)3-Trachea (Carcinoma & Benign stenosis)4-Thyroid Gland5-Parathyroid 6-Embryonal remnants (Thyroglossal cyst , 3rd

Branchial cyst)7-Paratracheal lymph nodes (Mets, Lymphoma)8-Recurrent laryngeal nerve paralysis

Laryngocele TypesInternal External Combined

Glottic SCC, axial contrast CT image shows a glottis mass in the left true cord reaching the anterior commissure (black asterisk), mild thickening of posterior commissure is noted (thick black arrow) with sclerosis of left arytenoid and left lamina of thyroid cartilage

Advanced SCC, axial CT+C shows a left cord mass (thin white arrows) reaching anterior commissure (asterisk), note the sclerosis of the left thyroid lamina and left cricoarytenoid joint (thin black arrows)

Zenker’s diverticulum

Cancer esophagus

CXR (a) shows an upper right paratracheal opacity narrowing the tracheal lumen (arrow) , CT+C (b) confirms the eccentric lobulated soft tissue mass that origins from the right anterolateral tracheal wall and narrows the lumen of the upper trachea , coronal MPR image at mediastinal window setting (c) better depicts the entire extent of the lesion

Mediastinal mass arising from the posterolateral wall of the trachea (a characteristic feature) with invasion of mediastinal fat and esophagus , Cystic adenoid carcinoma

Multinodular goiter Strap muscles on right side (yellow arrow) and presumed position of strap muscles on the left (blue arrow)

Multinodular goiter with intrathoracic extension

Medullary thyroid carcinoma in a 32-year-old man, (a) Transverse sonogram of the right lobe of the thyroid shows a large nodule with coarse calcification and posterior acoustic shadowing (arrows), (b) Axial CT shows the nodule with an internal focus of coarse calcification (arrows)

Anaplastic thyroid carcinoma in an 84-year-old woman, (a) Transverse sonogram of the left lobe of the thyroid shows an advanced tumor with infiltrative posterior margins (arrows) and invasion of prevertebral muscle, (b) Axial CT+C shows a large tumor that has invaded the prevertebral muscle (arrows)

Axial CT images in noncontrast (A) early post-contrast (B) and delayed post-contrast (C) phases demonstrate an intrathyroidal lesion with subtle hypodensity on precontrast imaging and delayed enhancement, this enhancement pattern is seen less commonly than early enhancement and washout

A 63-year-old woman with primary hyperparathyroidism, CT demonstrates avidly enhancing lesions in the orthotopic superior location (arrows) bilaterally with rapid washout of contrast greater than that of the adjacent thyroid gland (A and D: noncontrast phase; B and E: initial postcontrast “arterial” phase; C and F: delayed postcontrast phase), this patient underwent bilateral exploration, and bilateral superior parathyroid adenomas were found at surgery

Thyroid ectopia associated with the hyoid bone in three patients, (a) Axial CT+C of a 36-year-old man shows a thyroglossal duct cyst (arrowhead) intimately involved with the anterior aspect of the hyoid bone (black arrow); normal fat is preserved in the preepiglottic space (white arrow), (b, c) Sagittal (b) and axial (c) CT+C of a 49-year-old man depict a thyroglossal duct cyst that conforms to the embryologic course of the thyroglossal duct (magenta line in b), both anterior and posterior to the hyoid bone, and compresses the preepiglottic fat (arrow), (d) Axial CT+C image of a 28-year-old woman shows ectopic thyroid tissue in the same position as in c, appearing both anterior and posterior to the hyoid bone

Paramedian thyroglossal duct cyst

Third branchial cleft cyst, CT+C at the level of the thyroid cartilage reveals a large, well-defined, nonenhancing, water attenuation mass (m) deep to the right sternocleidomastoid muscle (s), medially displacing the common carotid artery and internal jugular vein

Axial view of CT scan of the chest (mediastinal windows) showing an enlarged left paratracheal lymph node in the aortopulmonary window (arrow)

Specific imaging characteristics of vocal cord paralysis (right side), a Widening of the right laryngeal ventricle (arrow), b Medial deviation and thickening of the right aryepiglottic fold (arrow), c Dilatation of the right piriform sinus (arrow)

Left RLN palsy, axial CT scan obtained at the level of the hypopharynx during quiet respiration shows left RLN palsy, note the distention of the ipsilateral piriform fossa with air (*) and the medially rotated, thickened ipsilateral aryepiglottic fold (arrow)

2-Carotid Space :a) Extension :-From skull base to the aortic arch-It traverses the suprahyoid & infrahyoidb) Contents :1-Carotid artery (Aneurysm, Thrombosis, Dissection)2-IJV (Thrombosis)3-Cranial Nerves (9-12), schwannoma & neurofibroma4-Lymph nodes (IJV chain of nodes), mets & lymphoma5-Embryologic remnants : 2nd Branchial cleft cyst6-Sympathetic Plexus : Paraganglioma (Carotid body

tumor)

Carotid aneurysm, (a) Non-contrast-enhanced axial CT shows a round soft tissue density mass in the right carotid space is seen, (b) CT+C shows a round mass showing homogeneous enhancement is seen in the right carotid space, (c) CT+C, coronal multiplanar reformation (MPR) shows the right internal carotid fusiform aneurysm and its top and bottom continuity with the internal carotid artery are shown

Thrombosis of IJV

Thrombosis of jugular vein

Thrombosis of the left internal jugular vein

Paraganglioma : T1+C at the level of the supraglottic larynx

Paraganglioma, (a) T1-weighted non-contrast MR, (b) CT+C

IJV lymph nodes, T- Thyroid gland, CA- Carotid Artery, IJV- Internal Jugular Vein, SCM- Sternocleidomastoid mu

2nd branchial cleft cyst

Carotid body tumor

3-Retropharyngeal Space :a) Extension :-Posterior potential midline space extends

superiorly to the base of the skull & inferiorly to the posterior mediastinum at the level of the tracheal bifurcation (T3 level)

b) Contents :1-Retropharyngeal abscess2-Fat (Lipoma & Liposarcoma)3-Lymph Nodes (Mets ,infection & Lymphoma)

Retropharyngeal abscess in a 3-year-old girl with fever and throat pain, (a) Lateral neck radiograph shows diffuse prevertebral soft tissue swelling (arrows), (b) CT+C demonstrates a mildly enhancing, thick-walled retropharyngeal fluid collection (arrow), these findings are indicative of an abscess

Retropharyngeal abscess, CT+C shows a large retropharyngeal fluid collection (arrows) with peripheral rimlike enhancement

Retropharyngeal lipoma

Axial CT+C of the skull base at the level of the hard palate shows an enhancing right lateral retropharyngeal lymph node (asterisk) and 2 enhancing left superficial parotid masses

4-Posterior Cervical Space :-Contents :1-Fat2-Cranial nerve XI (schwannoma, neurofibroma)3-Brachial plexus :-Schwannoma, neurofibroma-Direct invasion of apical lung (Pancoast tumor), breast

carcinoma & lymphoma4-Primitive Embryonic Lymph sacs (Cystic hygroma)5-Lymph nodes (Lymphoma, metastases, TB)

Lipoma, The mass has the signal intensity of fat on a T1 (a) and the signal is completely suppressed with fat suppression (b)

Cystic hygroma, axial CT+C show low-attenuation insinuating cystic mass (arrows) in the posterior triangle of left side of neck in a 3 month old child

Lymphangioma

Lymphoma, CT image at the level of the hyoid bone shows multiple rounded lesions medial to the sternocleidomastoid muscles and dorsal to the internal jugular veins, these bilateral multiple lesions are located in the posterior cervical space

5-Perivertebral Space :-Contents :1-Spine (OM, Tumors)2-Paraspinous muscles (Myositis, abscess ,

sarcoma, fibromatosis)3-Brachial plexus 4-Vertebral artery

Sarcoma, large soft tissue mass adjacent to the vertebral body centered in the perivertebral space

Benign fibrous tumor, T1+C

Vertebral artery dissection, high signal in the location of the right vertebral artery (click image for arrow), consistent with dissection

Vertebral artery dissection, T1 fat-saturated axial images show a dissection of the right vertebral artery between C1 and the foramen magnum, (A) T1 signal hyperintensity surrounding the right vertebral artery (upper arrow) as the artery courses between the posterior arch of C1 and the foramen magnum, the lower arrow points to hyperintensity in a different portion of the artery, indicating slow flow or occlusion, (B) The arrow points to a right vertebral artery hyperintensity, indicating slow flow or occlusion