Anatomy H&N Complete3

8/9/2019 Anatomy H&N Complete3

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Anatomy of Face andNeck

byPrem Nikomchaiprasert

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Nervous system of

face & neck Trigeminal n. (CN 5)

Facial n. (CN 7)

Accessory n. (CN 11)

Hypoglossal n. (CN 12)

Cervical plexus

Autonomic nervous system



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Trigeminal n. (CN5)

V1. Opthalmic n. :

superior orbital fissure

sensory n. V2. Maxillary n. :

foramen rotundum

sensory n.

V3. Mandibular n. :foramen ovale

mixed n. (motor +

sensory components)



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Trigeminal n. (CN5)

V1. Opthalmic n. : sensory n. Frontal n.

Supraorbital n. : scalp, upper eyelid Supratrochlear n. : forehead, upper

eyelid

Lacrimal n. : sphenopalatine gg. Nasociliary n. :

Long ciliary n. : eyeball, uppereyelid

Communicating br.: Ciliary gg. Posterior ethmoidal n. :

spenoid/ethmoid sinus Infratrochlear n. : lacrimal

apparatus, nasion Anterior ethmoidal n. :

Internal nasal br. Nasal cavity,ethmoidal aircelsl

External nasal br. : dorsum/ tip of nose



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Trigeminal n. (CN5)

V2. Maxillary n. : sensory n.

Meningeal n. : dura mater

Pterygopalatine n. :

sphenopalatine gg. Zygomatic n. :

Zygomaticotemporal n. :(zygomaticotemporal foramen): temporal area

Zygomaticofacial n. :(zygomaticofacial for.) : cheek

Posterior alveolar n.:maxillary sinus, upper molar

Infraorbital n. : upper molar,

lower eyelid, side of nose,upper lip



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Trigeminal n

. (CN5)

V3. Mandibular n. : Mixed n.

Branch of Trunk. Meningeal br. : dura mater

Medial terygoid n. : medialpterygoid m., tensor tympanim., tensor veli palatini m.

Anterior division br. : Masseteric n. : masseter m.

Ant. Deep temporal n. :

temporal m. Post. Deep temporal n. :

temporal m.

Lateral pterygoid n. : lat.Ptergoid m.

Buccal n. : skin of buccal area,buccal mucosa



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Trigeminal n. (CN5) V3. Mandibular n. : Mixed n. Posterior division br. :

Auriculotemporal n. :scalp, skin of preauricular

& temporal area, oticganglion Lingual n. : somatic

sensation ant. 2/3 tongue,submandibular gg.(chorda tympani), taste

buds ant 2/3 (chordatympani) Inferior alveolar n.

Dental br. : inferior alveolar Mental n. : chin

Mylohyoid n. : mylohyoidm., ant. belly of digastric m.



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* Retracting submandibular gland to posteroinferior direction :

lingual n., wharton¶s duct, hypoglossal n.



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Supranuclear segment : Cortex (precentral gyri)

Nuclear segment : facial nucleus, superiorsalivatory (pons)

Cerebellopontine angle : CN 7 + CN 8

Internal auditory canal : facial n., nervus

intermedius, CN8, internal auditory a. Labyrinthine segment : åûø õ

Facial n. (CN7)



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Geniculate ganglion :greater superficial petrosaln., lesser superficialpetrosal n.

Tympanic segment :

nerve to stapedius m.

Mastoid segment : chorda

tympani n. Extracranial segment : post

auricular n., nerve toposterior of digastric m.,pes anserinus

Facial n. (CN7)

123

4

1234



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Facial n. : Facialexpression

Temporal br. : m. ú zygoma

Z ygomatic br. :âú ûôinfraorbital

Bu

ccal br. : bu

ccinatorm., upper lip

Marginal mandibular br.: lower lip,

Cervical br. : plastysma

Facial n. (CN7)



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pes anserinus



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Stylomastoidforamen

->tympanomastoidfis. (lateral surface of tympanic bone) .

Tragal pointer

Facial n.

Digastric m.

Facial n. is usually

located ~1-1.5 cmdeep and inferior to

the tragal pointer



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Parotid Salivary Gland Parotid gland :

between zygomaticarch, ramus of mandible, masseterm., mastoid, styloid

process Duct : Stensen's duct

:~ 1.5 cm belowzygomatic arch, along

transverse facial a.,buccal br. (CN VII) crosses masseter,pierces buccinator,opening 2nd molar



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Parotid Salivary Gland

In gland : Facialn.(cervicofacial,temporofacial),

retromandibular v.,external carotid a.

maxillary a., superficialtemporal a. , deep parotid

LN

Surrounded : parotidfascia (superficial layer of

deep fascia)



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Frey syndrome(Gustatory sweating)

denervated postganglionicparasympathetic fibersgrowing and innervatingthe sweat gland after

removal of the parotid Facial n. injury

Direct anastomosis

Interposition graft

Hypoglossal-facialnerve anastomosis



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Accessory n. (CN.11)

Nucleus : nucleusambigus + C1-C5

Branch

Spinal part : SCM,trapezius m.

Accessory part : join vagus n.(pharyngeal m.,larynx, soft palate)

Course : Jugular foramen ->Posterior IJV, run obliquely

inferior/posterior SCM (Erb¶s point : posterior border of SCM thatgreater auricular n. turn around)



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Hypoglossal n. (CN.12)

Nucleus : Hypoglossalnucleus (medulla)

Hypoglossal canal

Distribution : All muscleof tongue (except palatoglossus CN10)

Course : crosssuperficial both ICA &ECA, ~1.5 cm abovecarotid bifurcation

CN XII ECA ICA



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Cervical Plexus

The cervical nerveplexus

- Cervical spinal nerve

C1-C41. Cutaneous branches

2. Ansa cervicalis (ansa

hypoglossi)3. Phrenic nerve

4. Communicatingbranches

5. Muscular branches



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1. Cutaneous Branches :sensation of cervicalskin

1. Lesser occipitaln.(C2,3) : auricle,postauricular area

2. Great auricular n.(C2,3) : auricle, skin(mastoid, paroitid area)

3. Transverse cervical n.(C2,3) : anteroir triangle4. Supraclavicular n.

(c3,4) : posterior triangle,manubrium sterni

Cervical Plexus



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2 Ansa cervicalis (Ansahypoglossi) :

Loop : SuperiorRamus (C1,2) andInferior Ramus(C2,3) Motor : Group of

infrahyoid m.[sternohyoid,sternothyroid,omohyoid m. ;except : thyrohyoid m. (C1)]

Cervical Plexus



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3 Phrenic nerve : Origin : ventralrami C3,4,5 Tract : anteriorscalenus m. to

thoracic inlet Supply : pleura,pericardium,diaphragm

Cervical Plexus



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4 Communicating branches

1. C2,3 and CN XII :Sternocleidomastoid

2. C3,4 and CN XII :Trapezius

5 Muscular branches

nerve root C1-C4 :

prevertebral m. (rectuscapitis, longus capitis,longus coli, scalenes,levator scapulae

Cervical Plexus



18/8/49 24 Phenic n. , cervical plexus : Deep to the fascial carpet

Montgomery : 110



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The Autonomic Nervous System

1. Sympathetic

2. Parasympathetic



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Sympathetic nervous system

1. Sympathetic nervoussystem

Origin : T1-T5

Ganglion

1.1 Superior cervicalsympathetic ganglion

1.2 Middle cervicalsympathetic ganglion

1.3 Inferior cervicals m athetic an lion



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1.1 Superior cervicalsympathetic ganglion

Origin : Sympatheticgg. C1-C4

Site : transverseprocess C2




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Branches : Communicating br. : CN9, CN 12

Pharyngeal br. : CN9, CN10 : pharyngeal

plexus External carotid nerves : perivascular plexuses

supply -->vss. of face, sweat glands of face,smooth m. of face

Internal carotid nerves Internal carotid plexuses : tympanic plexus,

greater superficial pertrosal n.

Cavernous plexuses : hypophyseal vvs. ,CN3,CN4, CN5, dilator palpillae




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1.2 Middle Cervical Sympathetic gg.Origin : Sympathetic gg. C5-C6Site : transverse process C6Branches :

1. Gray rami communicantes: spinal cord C5-C62. Ansa subclavia : inferior

cervical sympathetic gg.3. Thyroid branches : thyroid

gland4. Middle cervical cardiacnerve : cardiac plexuses




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1.3 Inferior Cervical Sympathetic Ganglion

Origin : C7-C8

Site : transverse process C7

82% âû thoracic sympathetic 1st :Cervicothoracic gg. (Stellate gg.)

Branches :

1. Gray rami Communicantes : spinal cord C6-T1

2. Ansa subclavia : middle cervical sympathetic gg.3. Inferior cervical cardiac n. : cardiac plexuses4. Vertebral plexuses : nerve plexuses (vertebral

a., basilar a., cerebral a., cerebellar a.)




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Note :

Cervical sympathetic gg. injury :Horner¶s syndrome (ptosis, miosis,facial anhidrosis)

Stellate Ganglionectomy :õ vasospasm of upper limb arteryin Raynaud¶s disease




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2. Parasympathetic Nervous System2.1 Ciliary gg. : CN3

: ciliary m.,spincter

pupillae m.2.2 Sphenopalatine gg. : CN7

: lacrimal gl., nasalcavity, hard/soft palate

2.3 Submandibular gg. : CN7

: Submandibular gl.,sublingual gl.

2.4 Otic gg. : CN9: Parotid gl.

Parasympathetic nervous system



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The Lymphatic System



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The six level of the neck

Superficial group

Head & Face Neck

Deep group

Lymphatic channels Right lymphatic duct

Thoracic duct



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Cervical Lymph Node Groups

The six level of the neck Level I : Submental and

Submandibular group

Level II : Upper ju gular group

Level III : Middle ju gu

lar group

Level IV : Lower ju gular group

Level V : posterior triangle group (supraclavicular node)

Level VI : Anteriorcompartment group



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Level IA

Bou ndaries

Superior : Symphysis of mandible

Inferior : body of hyoid

Medial/Lateral : Anteriorbellies of bilateraldigastric m.



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Level IA

LN : Submental nodes

Afferent :FOM, ant.tongue, anteriormandibular alveolar

ridge, lower lip

E fferent : LevelIB,II,III




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The six level of the neck Level IB

Bou ndaries

Superior : Body of

mandibleInferior : Posterior belly

of digastric muscle

Medial : Anterior bellyof digastric m.

Lateral : stylohyoid m.



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Level IB

LN : SubmandibularLN

Afferent : oral cavity,ant. nasal cavity,

midface, submandibular gland

E fferent : Level II,III



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Level II

Bou ndaries IIA

Superior : Skull base

Inferior : Horizontalplane defined by

inferior body of hyoidbone

Medial : Stylohyoid m.

Lateral : Accessory n.



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Bou ndaries IIB

Superior : Skull base

Medial : Accessory n.

Lateral : lateral border of SCM



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LN Level IIA & IIB: upper ju gular group,

Afferent Level IIA & IIB :

Oral cavity, base of tongue, nasal cavity, nasopharynx,oropharynx, hypopharynx,larynx, parotid gland

E fferent Level IIA & IIB :Level III, IV



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Level III

Bou ndaries

Su

perior : Horizontal planedefined by inferior border of hyoid

Inferior : Horizontal planedefined by inferior border of

cricoid cartilageMedial : Lateral border of

sternohyoid m.

Lateral : lateral border of

SCM



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Level III

LN :Middle ju gular group

Afferent : Oralcavity, nasopharynx,oropharynx,

hypopharynx, larynx

E fferent : Level IV



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The six level of the neck Level IV

Bou ndaries

Superior : Horizontal plane

defined by inferior borderof cricoid cartilage

Inferior : Clavicle

Medial : lateral border of sternohyoid m.

Lateral : lateral border of SCM



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The six level of the neck Level IV LN : Lower ju gular

group, inferior deep

cervical LN Afferent : Hypopharynx,

thyroid gland, cervical

esophagus, larynx E fferent : ju gular

lymphatic tru nk



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The six level of the neck Level VA

Bou ndaries

Inferior : Horizontal plane

defined by lower border of cricoid cartilage

Medial : Post. border of

SCMLateral : Ant. border of

trapezius m.

LN : accessory chain



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The six level of the neck Level VB Bou ndariesSuperior : Horizontal plane

defined by lower border of cricoid cartilage

Inferior : Clavicle

Medial : post. border of SCM

Lateral : ant. border of trapeziusm.

LN : transverse cervical chain,supraclavicular nodes



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Afferent :Level VA & VB : Nasopharynx, oropharynxcutaneous of posterior scalp

& neck, aerodigestive tract(Supraclavicular nodes )

E fferent :Level VA & VB :Level IV, ju gularlymphatic tru nk, Rightlymphatic duct, thoracicduct (Lt)



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Level VI

Bou ndaries

Superior : Hyoid bone

Inferior : Suprasternal notch

Lateral : Common carotida.



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Level VI

LN : pre/para tracheal nodes, precricoid

(Delphian) node,perithyroidal nodes and nodes along RLN

Afferent:

Thyroid gland, glottic &subglottic larynx,pyriform sinus, cervicalesophagus

E fferent : Level II, III, IV



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Neck Dissection Classification

1. Radical neck dissection 2. Modified radical neck dissection

3. Selective neck dissection

4. Extended neck dissection



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Neck Dissection

Radical NeckDissection

Procedure removal :Ipsilateralcervical lymph

node groups I-V,spinal accessory

n., IJV, SCM



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Neck dissection

Modified Radical ND

Level I-V LN group

Preservation of one ormore :

Spinal accessory n.

Internal ju gular v.

SCM

cumming 2627B



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Neck dissection Selective Neck Dissection

E n bloc removal one or more LN groups that are risk for

harboring metastatic cancer

Extended Neck Dissection

Any of node dissection classification with remove

either LN, vascular, neural, muscular structure ( retropharyngeal LN, hypoglossal n., levator scapulae m.,carotid a.)



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Neck dissectionOral cavity cancer :

Supraomohyoid neckdissection (SOHND)

SND (Level I-III) (+level IV in tonguecancer)

; Nodal metas I-III : SND(I-IV)

; N2c : Contralateral ND

Cumming2628 116-9



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Neck dissectionCA oropharynx, hypopharynx

and larynx :

Lateral neck dissection : SND(Level II-IV)

; Cancer involving pharyngealwall : SND (II-IV,retropharyngeal nodes)

; Cancer extendind below the

glottis : SND (II-IV and VI)

116-12



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Neck dissection CA posterior scalp andupper neck :

Posterolateral neckdissection : SND(II-V,postauricular andsuboccipital )

preauricular, ant. Scalp,

temporal region : SND(parotid and facial nodes,level IA, IB, II and III)

116-14



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Neck dissection Midline structures of

anterior lower neck

CA thyroid, advanced glotticcancer, subglottic larynxcancer, advanced pyriformsinus cancer, cervicalesophageal/tracheal cancer

Anterior neck dissection or

central compartment dissection SND (level VI)

116-15



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Neck dissection

Midline structures of anterior lower neck

; Metas below su

prasternal notch : SND (IV,superior mediastinal nodes)

; CA Thyroid cancer with nodal metas Level V :SND (VI and II-V)

116-16



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The Lymphatic System Superficial group

Head & Face

Neck Deep group

Lymphatic channels

Right lymphatic duct

Thoracic duct



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Superficial group Face & Head

² Occipital nodes² Retroauricular

nodes² Anterior

auricular nodes²

Superficialparotid nodes

² Facial nodes



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Superficial group Neck

Submental nodes

Submandibular nodes

External Ju gular

nodes Anterior ju gular

nodes



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Deep group² Accessory Chain

² TransverseCervical chain

² Juxtavisceral

Nodes² Deep cervical

Nodes




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The Lymphatic SystemDeep group

Juxtavisceral Nodes Infrahyoid group : thyrohyoid membrane

Prelaryngeal group : cricothyroid ligament

Pretracheal group : along inferior thyroid artery

Paratracheal group :along recurrent laryngeal n.

Th L ph ti S t



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The Lymphatic SystemDeep group

4. Deep Cervical Nodes

4.1 Superior DeepCervical Nodes

RetropharyngealNodes

Deep parotids Nodes

Ju gulo-digastric Node

Ju gulo-omohyoid Node 4.2 Inferior Deep

Cervical Nodes



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Lymphatic Channels

Right Lymphatic Duct

Origin :

Ju gular lymphatic tru nk (Rt) (inferior deep cervicalLN, Transverse cervical chain)

Subclavian lymphatic tru nk (Rt)

Bronchomediastinal lymphatic tru nk (Rt) Distal E nd : Right Subclavian v. ö

è Right Subclavian v. âû Right Internal

Ju

gu

lar v.



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Lymphatic Channels

2. Thoracic DuctOrigin : Lumbar lymphatic tru nk

(Rt&Lt) Intestinal lymphatic tru nk Ju gular lymphatic tru nk

(Lt), transvercervicallymphatic tru nk (Lt),

subclavian lymphatic tru nk(Lt)

Distal E nd : öè Left Subclavian v. âû Left

Internal Ju

gu

lar v.



Tissue plane and space

offace & neck



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Cervical fascia1. Superficial cervical fascia

2. Deep cervical fascia- Superficial layer

- Middle layer

- Deep layer



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Superficial cervical fascia

Superficial musculoaponeurosis(SMAS)

Fibromuscular fascia Invests the muscles of facial

expressionBoundarySuperior zygomatic archInferior platysmaPosterior SCM

Anterior orbicularis orisMelolabial crease,upper lip Ant sup orbicularis oculizygomatic major&minor



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Superficialmusculoaponeurosis(SMAS)

Branch of CN VII deep toSMAS

Lower cheek br CN VII deepto masseteric fascia

Potential space between SMAS& masseteric fascia(avascularplane) : safely dissect

Important to Rhitidectomy



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SMAS FACE LIFT



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Superficial musculoaponeurosis(SMAS)

Temporal br.:

- most superficial br,exist superiorparotid gl crossed junction ant 1/3 & post 2/3 zygomatic arch

- Dissect: forhead lift+face lift

Zygomatic br :

- lie drawn targusmalar eminence

- injury mild synkinesis lower eyelid



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Superficial musculoaponeurosis(SMAS) Buccal br :- exist ant parotid,on to surface

massester m.deep to fascia pass

buccal fat - injury sagging upper lip Mandibular br:- exist inf parotid, extened along

platysma- 1-2 cm below body mandible ant

to facial a cross mandible,N is oninf mandible

- Injury : liposuction



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Space between superficial cervicalfascia and superficial layer of deepcervical fascia contains :

M. : platysma m.,

N. : great auricular n

Vessel : ant&ext.jugular v

Superficial lymphatic

; infection of this space : I&D



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S fi i l l f



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Superficial layer of

the deep cervical fasciaRule of two

- envelopes 2 m : trapezius,SCM

; masticator m. (masseter m.,pterygoid m., tempolaris m.),ant. Belly of digastric, mylohyoidm.

- envelopes 2 glands :

submandibular,parotid- form 2 spaces :space of posterior triangle,suprasternalspace of BURN

S fi i l l f



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the deep cervical fasciaSuperiorly

Mastoid processes of

temporal bones Mandible

1. Internal layer:coverpterygoid mskullbase

2. External layer:covermasseter m.,

zygomatic arches

S fi i l l f



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the deep cervical fascia Inferior

Manubrium

Clavicles

Acromion

Posterior Spinous processes of cervical

vertebrae and nuchal

ligament Superior nuchal line of

occipital bone

Spread anterolatteral

Anterior attach hyoid



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Superficial Layer of

the Deep Cervical Fascia

Middl l f th d



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Middle layer of the deep

cervical fasciaMiddle layer (DCF)

Muscular division

Viceral division

Muscular division

Surrounds infrahyoid(strap) muscles:

Sternohyoid,Sternothyroid, Omohyoid,Thyrohyoid

Superior: hyoid,thyroid

Inferior: clavicle,sternum

Middl l f th d



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cervical fascia Visceral division Envelopes : thyroid,

trachea, esophagus Envelopes : pharyngeal

constrictor & buccinatorbucco-pharyngeal fascia& form ant.wall

retropharyngeal space Buccopharyngeal fascia

form midline raphe inposterior midline adhere toalar & fuse~ T2

cumming*

Middl l f th d



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cervical fascia Visceral division

Posterosuperior:base of

skull Anterosuperior:thyroid

cartilage & hyoid bone

Inferior:pericardium

Laterally both devisioncontribute carotid sheath

Muscular fascia

Middl L f



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Middle Layer of the Deep Cervical Fascia

Deep layer of



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Deep layer of the deep cervical fascia

1. Prevertebral division Anterior: adhere

vertebral body,extendskull base down lengthspine

Posterior:aroundscalene m,vertrebral m

Envelops vertrebral vv,brachial plexus,phrenicn, subclavian vv,axillary

sheath

1. Prevertrebral division

2. Alar division

Deep layer of



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Deep layer of

the deep cervical fascia Alar division

Between : middle layer& prevertrebral fascia

Posterior wall of retropharyngeal space

Extendes : base of skullto level of T2 (fuses

with visceral fascia)

Alardivision



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Deep Layer of

Deep Cervical Fascia

S f k



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Space of neck

Suprahyoid space Submandibular space

Parapharyngeal space

Masticator space

Parotid space Peritonsillar space

Infrahyoid space Suprasternal space

Anterior visceral space

Posterior cervical space

Space involving entirelength of neck

Carotid space

Retropharyngeal space Danger space

Prevertebral space



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Space of neck

Suprahyoid space Submandibular space


Masticator space

Parotid space

Peritonsillar space



S b dib l



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Submandibular space

Sublingual spaceBoundary :

Superior : floor of mouth Anterior&Lateral : mandible

Posterior : intrinsic muscleof base of tongueInferior: mylohyoid

Component :1. Anterior extension of hyoglossus m.

2. Lingual nerve, CN 9, CN123. Lingual artery and vein4. Sublingual gland and duct 5. Deep portion of submandibular gl6. Whartons duct

Submandibular space



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Submaxillary spaceBoundary :Superior mylohyoid Anterior SLDFInferior hyoid bone

Posterior posterior digastricComponent :1. Anterior belly of digastric

muscle2. Superficial portion of

submandibular gland3. Submental and submandibular

LN4. Facial artery and vein5. Inferior loop of CN XII

6. Fat

Submandibular space

Submandibular space



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Submandibular space

Sublingual continue submandibular via the posteriormargin of the mylohyoid muscle

Source infection: Odontogenic, oral trauma,submaxillary or sublingual sialadenitis, or abscess of mandibular teeth 1st molarsublingual

2nd,3rd molarsubmandibular Clinical:

Ludwig angina

drooling,pain, dysphagia,submandibular mass, and

dyspnea or airwaycompromise



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Boundary :

superior base of skull

inferior hyoid boneanterior pterygomandibular

raphe

posterior prevertebral fascia

medial superior constrictor

Lateral parotid, mandible,

lateral pterygoid

h l



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Prestyloid Muscular compartment

Medialtonsillar fossa

Lateralmedial pterygoid

Contains fat, connectivetissue, nodes

Poststyloid Neurovascular

compartment Carotid sheath

Cranial nerves IX, X, XI, XII

Sympathetic chain



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= Lat. Pharngeal ,pharyngomaxillary ,peripharyngeal space Infection in prestyloid:

neck pain,odynophagia,trismus swelling below jawangle,displace pharyngeal wall

Infection in poststyloid:- sepsis,little trismus,Horners syn.,

paresis CN IX to XII

- internal jugular thrombosis

(Lemierres syn.),- carotid rupture

Masticator space



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Masticator space

Masticator space :3

space* cumming

masseteric

temporal

Ptrygoid

Component :

1. Muscles of mastication : medial andlateral pterygoids, masseter muscle

2. Tendon of insertion of temporalismuscle

3. Branches of CN V3 (Inferior alveolarnerve)

4. Branches of internal maxillary artery5. The ramus and posterior body of

mandible

Clinical : extreme trismus,edema&tender post. ramus mandible

Masticator space



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Temporal space Superficial temporal space :

Medially temporalis mLaterally superficial temporalis

fascia Deep temporal space :

Medially periosteum of temporalbone

Laterally temporalis muscle

Infratemporal spaceMedially lat.plate pterygoidLaterally deep temporal spacesuperior skull base

Masticator space

Ma ticato ace



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Temporal space Component :

- internal maxillaryartery

- mandibular vesselsand nerves

Clinical : pain temporalm ,trismus ,occasionaldeviation of jaw toaffect side

Masticator space

Masticator space



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Masseteric spaceBoundary :

Lateral masseter m

Medial mandible

Source : spread frombuccal space infection

Clinical : trismus,postero inferior face swelling

Masticator space

Masticator space



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Masticator space

Pterygomandibularspace

Boundary

Sup Lateral pterygoid m Inf Pterygomasseteric

sling

Ant Pterygomandibular

raphae Post Parotid

Med Medial pterygoid

Lat Medial ramus

Masticator space



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Pterygomandibularspace

Infection would lead totrismus,on swelling

Infection most spreadfrom sublingualsubmandibular space

Commonly would lead tolateral pharyngeal spaceinvolvement.

3 space(temporal,masseteric,pterygomandibuar sp)

communicate freely

Masticator space

P tid S



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Parotid Space

Bounded bysuperficial layer of

deep cervical fascia Posterior to

masticator and lateralto PPS

Extend from EAC >inferior edge of angleof mandible

Parotid space



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Parotid space

Component :

1. Parotid gland and proximal duct

2. Facial nerve

3. retromandibular vein, Br. of external carotid and internalmaxillary artery

4. Intraparotid LN

Fascia not cover upper inner

surface parotid gl

communicatePPS

Source infection : parotid

Clinical :swelling angle of jawwithout trismus

Peritonsillar Space



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Peritonsillar Space

Boundary :

Medially capsule of tonsil

Laterally superiorconstrictor

Ant&Post tonsillarpillars

Component :

- loose connectivetissue

Peritonsillar space



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Peritonsillar space

Source: tonsil,pharynx

Clinical: dysphagia

muffle voice,trismustonsil displace,uvular

deviate across midline

to opposite side Infect involve

juxtrapharyngeal space

S f k



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Space of neck

Infrahyoid space

Suprasternal space

Anterior visceralspace

Posterior cervical

space

Suprasternal space



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113

Suprasternal space

Suprasternal space of BURN

SLDF split attach to

anterior and posteriorsurface of manubrium

Component : 2 head of SCM, lower end of

ant.jugular vein, the jugular arch, and LN

Closed space

Suprasternalsp.

Anterior Visceral Space



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Boundary :

Superior hyoid bone

Inferior mediastinum

Anterior SLDFPosterior RPS,prevertebral

Lateral PPS,carotid fascia

Component :Pharynx,larynx,esophagus,

trachea,thyroid&parathyroid gl

RLN, LN




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Pretracheal space

Source :

most infectionperforate by instrument FB ,external trauma

Clinical :

Dysphagia,hoarseness,dyspnea,U AO


P t i i l



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Posterior cervical space

Boundary :

Floor deep layer of DCF

Superior superficial layer of DCF

Inferior omohyoid

Extend from skull base clavicle

Posterior triangle portion

posterolateral to carotid spacebetween SCM and trapezius Component : fat, spinal

accessory n., spinal accessorychain of deep cervical nodes



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Space of neckSpace involving entire

length of neck

Carotid space Retropharyngeal space

Danger space

Prevertebral space

C tid



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Carotid space

Boundary :

Superior skull base

Inferior aortic arch

Anterior SCM

Posterior prevertebral space

Medial visceral space

Lateral SCM

Component

- carotid a

- IJV

- CN X

Carotid space

Carotid space



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Carotid space

Mosher in 1929 Lincoln Highway

Source: most infected PPScarotid space

Clinical:tender&swelling SCM,torticollis,vocal cordparalysis

Complication:IJV thrombosis (Lemierresyndrome) ,carotid rupture

Retropharyngeal Space



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Retropharyngeal Space

Boundary :

Superior skull base

Inferior superiormediastinum,~T2cumming

Anterior pharynx &esophagus

Posterior alar fascia

Lateral carotid sheath

Retropharyngeal space



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Retropharyngeal space

Component: LN,CNT

Source: infectednose,NP,adenoid,PNS (most

in child)

in adult :instrument, FB ,trauma

Clincal:unilat midline

abscess pain, dysphagia,nuchal rigidity,air waycompromise

Danger space



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Boundary :

Superior skull base

Inferior diaphragm

Anterior alar fasciaPosterior prevertebral

fascia

Lateral transverseprocess of vertebrae

Component : CNT

Danger space

Danger space



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Danger space

Source: PPS,retropharyngeal,prevertrebral space

Clinical:similar retropharyngeal space infecion

Complication:mediastinitis

Prevertrebral space



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Prevertrebral space

Boundary :

Superior skull base

Inferior coccyx

Anterior prevertebral fascia

Posterior vertebral bodies

Lateral transverse process

of vertebrae

Component

1. Dense areolar tissue forming a

very compact space* LEE



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Prevertrebral space

Source: pyogenic/TB spine

(Potts abscess) , trauma

Clinical : midline abscess

,vertrebral osteomyelitis ,spinal instability,similarretropharyngeal spaceinfecion



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Imaging Lateral neck plain film

Screening exam

Normal:

7mm at C-2

14mm at C-6 for kids

22mm at C-6 for adults

Technique dependent

Extension

Inspiration

Sensitivity 83%,compared to CT 100%

Surgery



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Surgery

External drainage Landmarks

Tip of greater horn of hyoid

Cricoid cartilage Styloid process

SCM

Transoral drainage

Needle aspiration

Network of infectious



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extension

Submandibular masticater temporal

Peritonsillar PPS parotid

Carotid danger RPS

prevertebral

Ant.cervical mediastinum

Th k



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Thank you

References : Byron J. Bailey et al, Head&Neck surgery-

otolaryngology, 3rdedition 2001

Charles W. Cummings et al, CummingsOtolaryngology- Head&Neck surgery,4th edition 2005

Jeffrey Buyten, MD Francis B. Quinn, MD UTMB Department of Otolaryngology, Deep Neck Space

Infections 2005 ë , ù ú öú÷ö, å üÿúù , ûîø è

ö â åü âö ø 2 ÿ ÿ å èø 3 û åÿû ëë 2541

âüâûâú tissue plane space in H&N , ÿ. ÿ



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Important Landmarks

Important Landmarks



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Important Landmarks Submental Triangle

Anterior Triangle

Submandibular Triangle

Carotid Triangle

Muscular Triangle

Posterior Triangle

Occipital Triangle

Supraclavicular(Omoclavicular)Triangle

Important Landmarks



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Important Landmarks

Submental Triangle Boundaries : Hyoid,

Lt/Rt anterior belly

digastric m. Contain :

Submental vss.

Submental LN

Mylohyoid m.

Important Landmarks



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p

Anterior Triangle Boundaries : Midline

of neck , lower border

of mandible, anteriorborder of sternocleidomastoid m.

Contain Submandible triangle

Carotid Triangle

Muscular Triangle

Important Landmarks



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Important Landmarks

SubmandibularTriangle

Boundaries : Anterior belly

of digastric m.

Posterior bellyof digastric m.

Lower border of mandible

Important Landmarks



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Important Landmarks

Submandibular Triangle

Contain

Submandibular gland and Wharton·s duct

Submandibular LN

Lingu

al n., CN12, su

bmandibu

lar gg Lingual a., facial a., anterior facial v.

Important Landmarks



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Important Landmarks

Carotid Triangle

Boundaries :

Posterior belly of digastric m.

Superior belly of omohyoid m.

Anterior border of sternocleidomastoid m.

Important Landmarks



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Important Landmarks

Carotid Triangle

Contain

Common carotid a., carotid sinus, internalcarotid a., external carotid a. ( and br. : superiorthyroid a., ascending pharyngeal a., lingual a.,facial a.)

Internal ju

gu

lar v., ( and br. : su

perior thyroid v.,lingual v., facial v. )

Deep cervical LN

CN10, CN11, CN12, Ansa hypoglossi, cervical

Important Landmarks



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Important Landmarks Muscular Triangle

Boundaries :

Midline

Superior belly of omohyoid m.

Anterior border

of sternocleidomastoid m.

Important Landmarks



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Muscular Triangle

Contain

Thyroid gl, parathyroid gl, larynx, trachea,esophagus

Infrahyoid m., infrahyoid fascia Superior/inferior thyroid a.,

Superior/middle/inferior thyroid v., anteriorjugular v.

Internl laryngeal n., external laryngeal n., recurrentlaryngeal n.

Infrahyoid LN, paratracheal LN., anterior jugular

LN, right lymphatic du

ct, thoracic du

ct

Important Landmarks



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Important Landmarks Posterior Triangle

Boundaries : posteriorborder of sternocleidomastoid,anterior border of trapezius m.,middle(1/3) part of clavicle

Contain Occipital Triangle

Supraclavicular

(Omoclavicular) Triangle

Important Landmarks



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Important Landmarks

Ocipital Triangle

Boundaries :

Posterior border of

sternocleidomastoid

Anterior border of trapezius m.

Inferior belly of omohyoid m.

Important Landmarks



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Important Landmarks

Ocipital Triangle

Contain

CN11, lesser occipital n., great auricular n.,dorsal scapular n., transverse cervical n.,supraclavicular n.

Transverse cervical a.

Transverse cervical v., external jugular v.

Accessory cervical chain, transverse cervicalchain, external jugular LN

Important Landmarks



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Important Landmarks

SupraclavicularTriangle

Boundaries :

Posterior border of sternocleidomastoid

Inferior belly of

omohyoid m. Middle(1/3) part of

clavicle

Anatomy H&N Complete3

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