Anatomy of Deep Neck Spaces and

its Surgical importance

Dr. Ajay ManickamMS (ENT) JUNIOR RESIDENT

R.G.Kar Medical College

Extension Anteriorly from lower border of mandible to

upper surface of manubrium of sternum Posteriorly from superior nuchal line on

occipital bone of skull to c7 and t1 vertebrae

Introduction

Skin – cervical

dermatome Muscles – cervical

myotomes The branchial

apparatus

Developmental Anatomy

4 compartments provide longitudinal

organisation Visceral compartment – anterior – digestive,

respiratory & endocrine glands Vertebral compartment – posterior – cervical

vertebrae, spinal cord, cervical nerves and muscles

2 vascular compartments – lateral – major blood vessels and vagus nerve

Compartments

Fascia

Superficial

Deep 1.Superficial

layer2.Middle layer3. Deep laayer

Fascial layers

Thin sheet of muscle

platysma, begins in superficial fascia of thorax, attaches to mandible and blend with muscles of face

Penetrated by blood vessel that supply neck skin

Subplatysmal flap protects blood supply to the skin

Facial nerve- cervical branch

Superficial fascia

Superficial layer Arises from ligamentum nuchaeand spinous

process of cervical vertebrae Splits to enclose

trapezius,omohyoid,sternocleidomastoid,strap muscles and parotid gland

Deep cervical fascia

Middle layer Derived from superior layer of deep

cervical fascia encircles trachea, thyroid, esophagus

A. Investing Layer B. Muscular Pretracheal Layer C. Visceral Pretracheal Layer D. Prevertebral Layer

Deep cervical fascia

Deep layer Arise from ligamentum nuchaeand

spinous process of cervical vertebra

Splits to enclose postvertebral muscles, form layer over vertebrae

Floor of post triangle Allows pharynx to glide during

deglutition Extends in lower region of neck to

axilla – axillary sheath

Deep cervical fascia

Superficial layer of cervical fascia medial to

sternocleidomastoid muscle Contains 80% LN,carotid artery, IJV,vagus

nerve

Carotid sheath

Triangles of neck

Fascial spaces

Between the fascial layers in the neck are spaces that may provide conduit for the spread of infectionsThey contain loose areolar fascia

Deep Neck Spaces are described in relation to

the Hyoid bone.

A. Entire length of the neck.

B. Suprahyoid.

C. Infrahyoid.

Classification of neck spaces

1. Superficial neck space 2. Deep neck spaces Retropharyngeal space Danger space of Gillette Pre vertebral space

Involving entire length of neck

Sub mental space

Submandibular space -Sublingual space -Sub maxillary space

Peri tonsillar space

Parotid space

Para pharyngeal space

Masticator space

Supra-hyoid

Pretracheal space

Infra hyoid

Extends from base of skull to

tracheal bifurcation Between two parapharyngeal

space Superior – skull base Anterior – musculature of pharynx Posteror limit – prevertebral fascia Communicates with – mediastinum It is divided into two lateral

compartments space of gillete by fibrous raphe

Retropharyngeal space

There are a group of inconsistent nodes in the

retropharyngeal space known as the Glands of Henle which regresses by 5 yrs of age. Suppuration of these nodes result in Ac. Retropharyngeal abscess and thus commoner in children.

There is also a constant group of nodes called the Rouvier’s nodes which are the first nodes to enlarge in cases of nasopharyngeal and posterior sinus malignancies.

Retropharyngeal space

Base of skull to diaphragm Located between the pre vertebral fascia and

alar fascia Retro pharyngeal space proper is in front of

alar fascia This is called danger space because of easy

route of mediastinitis

Danger space

Potential space between cervical vertebra posteriorly and

the prevertebral fascia anteriorly Extends from base of skull to coccyx Tuberculosis of spine, penetrating traumas chief source of

infections

Prevertebral space

Midline space between anterior bellies of

digastric muscles Contents – areolar tissue, lymphnode, ant

jugular vein

Submental space

Includes submaxillary + sublingual,

divided by mylohyoid muscle Superficial boundary – submandibular

gland & digastric muscle Deep boundary – mylohyoid muscle Lies between mucous membrane of

floor of mouth& tongue on oneside & superficial layer of deep cervical fascia, from mandible to hyoid bone

Comunicates with floor of the mouth

Submandibular space

Between capsule of tonsil & superior

constrictor Located lateral to the tonsils Infection source is mainly tonsillar crypts Communicates with retropharyngeal &

parapharyngeal space

Peritonsillar space

Boundaries The space is circumscribed by the superficial layer of the deep cervical fascia superior margin: external auditory canal; apex of the mastoid process inferior margin: inferior mandibular margin (although the parotid tail can extend further inferiorly below the angle of the mandible) anterior margin: masticator space contents parotid glandsparotid lymph nodes facial nerve (CN VII)external carotid artery retromandibular veinFascial layer is very thick superficially , very thin on deep side of gland- burst to parapharyngeal space- mediastinum

Parotid space

Inverted pyramid shaped

Para pharyngeal space

Located between superficial layer of deep

cervical fascia & muscles of mastication Extends from base of skull to lower border of

mandible Contents

muscles of masticationramus and body of mandibleinferior alveolar nerve,vein,arterymandibular division of the trigeminal nerve (V3)enters the masticator space via the foramen ovale

Masticator space

Anterior and lateral to thyroid cartilage Contains delphian node Communicates – superior mediastinum

Pretracheal space

Neck nodes

Neck space infections

Rare, but life threatening infection,that causes

progressive necrosis of the subcutaneous fat and fascia and causes secondary necrosis of the overlying skin.

ETIOLOGY - Odontogenic infections - Tonsillar infections - As a complication of other DNSI

Necrotizing fascitis

Cellulitis with disproportionate pain.

Reduced skin sensation of the involved areas.

Outer zone- Erythema Intermediate zone- Tender ecchymosis Central zone- Vesiculation

Soft tissue crepitus due to gas formation.

Hypocalcemia , Hyponatremia , Dehydration

Necrotizing fascitis

Early correction of fluid and

electrolyte imbalance.

I.V Penicillin and I.V Metronidazole are the mainstays of the antimicrobial therapy.

Surgical debridement of all necrotic areas is the key to successful treatment of the patient.

Skin grafting after wound debridement

Necrotizing fascitis

Life threatening

infection URI, tuberculous

lymphadenitis X-Ray soft tissue

neck lateral view, CT

Incision & drainage

Retropharyngeal space infections

Children <3yDysphagia and difficulty in breathing. Stridor and Croupy cough maybe present,Torticollis,Bulge in the posterior

pharyngeal wall. The child is febrile and adopts apeculiar posture with the neck flexed and the head extended. Straightening of the cervicalspine known as Ramrod Spine

Radiographic picture of the lateralview of neck (soft tissue) showswidening of the prevertebralspace and even the presence of gas shadows(air fluid levels).

Acute retropharyngeal

abscess

Incision and Drainage of abscess is done,usually without anaesthesia

as there is risk of rupture during intubation.[the child is kept supine with head low and mouth opened with a gag.A vertical incision is given in the most fluctuant area.Suction should always be available to prevent aspiration]

Systemic Antibiotics-Broad spectrum antibiotics like Ceftriaxone and Metronidazole may be used.

Tracheostomy in airway obstruction

Acute retropharyngeal

abscess

TB Spine(Pott’s Spine) where the pus collects

in the prevertebral space. TB of retropharyngeal lymph nodes present in

the retropharyngeal space proper. Post traumatic-vertebral fracture. Spread from Parapharyngeal abscess

Chronic retropharyngeal

abscess

Discomfort in the throat,mild dysphagia. Pain is absent due to cold abscess. Bulge in the posterior pharyngeal wall

either centrally or laterally. Neck may show Tubercular lymph nodes. Treatment - Incision and drainage of

abscess is done through a vertical incision along the anterior border of the sternocleidomastoid for low abscesses, or along its posterior border for high abscesses.

Full course of anti-Tubercular therapy is given

Retropharyngeal space infections

Odontogenic infection – submandibular space

– submental region Mandibular fractures Cutaneous infection Treatment- I&D

Sub mental abscess

Drooling, trismus,

dysphagia, stridor caused by laryngeal edema, and elevation of the posterior tongue against the palate , fever, tachycardia.

Aerobe, anaerobe Maintanence of airway Needle aspiration USG or

CT guided

Submandibular space infection

Toothache, fever, odynophagia, drooling. SUBLINGUAL space infection -floor of mouth swelling. -tongue elevation. SUBMAXILLARY space infection -brawny/woody tender swelling below the chin. Trismus. Stridor- due to falling back of tongue, laryngeal edema. Initially there is cellulitis which is followed by abscess

formation.

Submandibular space infection

Ludwig’s angina

Xray showing supraglottic swelling

Systemic antibiotics- Ceftriaxone/Cefuroxime and Metronidazole/Clindamycin.

Tracheostomy if airway is compromised after unsuccessful attempts at oral/nasal intubations.

Incision and Drainage of Abscess: intraoral—sublingually localised infection. extraoral—submaxillary infection.

A transverse incision extending from one angle of mandible to the other is made with vertical opening of midline musculature of tongue with a blunt haemostat

Ludwig’s angina

Quinsy Tonsillitis Odynophagia, hot

potato voice Complication –

ludwig’s angina, adjacent spaces

Needle aspiration I&D

Peri tonsillar space infection

Peritonsillar abscess is opened at the

point of maximum bulge above the upper pole or just lateral to the point of junctionof anterior pillar and a horizontal line drawn through the base of the uvula

Interval Tonsillectomy maybe done 4 to 6 weeks after an attack of Quincy.

Abscess/Hot Tonsillectomy are preffered by some instead of Incision and drainage. This has the risk of abscess rupture during anaesthesia and excessive bleeding at the time of operation.

Incision & drainage

Acute/Chronic infections of tonsils and

adenoid, bursting of the peritonsillar abscess. Dental infection usually from the lower last

molar. From Bezold abscess or Petrositis. Infections of parotid, retropharyngeal and

submaxillary spaces. Penetrating injuries of neck, injection of L.A for

mandibular nerve block or for tonsillectomy.

Parapharyngeal space infections

More common in adults Infective process of upper

aerodigestive tract, Trismus, pyrexia, tonsil may

be medially displaced USG, CT, needle aspiration

under CT or USG guidance Small loculated –

conservatively Large collections – external

approach, medial to carotid sheath, isertion of a drain

Parapharyngeal space infections

Incision and Drainage -Usually done under G.A. -Pre-op tracheostomy if trismus is marked. -Drained by a horizontal incision made 2-3 cms below

the angle of the mandible.Blunt dissection is done along the inner surface of the medial pterygoid towards styloid process and the abscess is evacuated and a drain is inserted.

[Transoral drainage should never be done due to the danger of the great vessels which pass through this space.]

Parapharyngeal space infection

Causes Ascent of bacterial

infection(Staphylococcus, Streptococcus,Haemophilus) to a dehydrated parotid via Stenson’s duct from oral cavity.

Suppuration of intra-parotid LNs. Spread of infection from the

auditory canal via the cartlaginous fissures of Santorini or the bony foramen of Huschke.

Parotid space infection

Symptoms Spontaneous onset of painful parotid enlargement followed by fever and cellulitis which then turns into fluctuant parotid abscess. Pain and induration over the parotid. Pitting edema over the parotid area differentiates parotid abscess from simple parotitisParotid massage expresses pus into the oral cavity via the Stenson’s duct ,opposite the upper 2nd molar.

Parotid space infection

Treatment:-Maintainence of oral hygiene, IV antibioticsIncision and Drainage:- -Blair’s incision made. -Multiple incisions made through fascia

parallel to branches of the facial nerve. -Blunt dissection done to evacuate the pus. -Drains are placed.

Parotid space