Surgical anatomy of deep neck spaces

SURGICAL ANATOMY OF DEEP NECK SPACES

DR MANOHAR SURYAWANSHIENT RESIDENT INHS ASVINI

Introduction

• Cervical fascia envelope the muscles, nerves, vessels

and viscera of the neck

• It forms planes and potential spaces that serve to

divide the neck into functional units

• The cervical fascia functions to both direct and limit

the spread of disease processes in the neck

PARTS OF CERVICAL FASCIA

A) Superficial cervical fascia

B) Deep cervical fascia

A) Superficial cervical fascia

• Thin layer that invests the platysma muscle

• Penetrated by the blood vessels that supply the neck

skin

• Deep cervical fascia consists of 3 separate fascia:

Investing layer

• Superior attachments: inferior border of

the mandible, hyoid bone, superior nuchal line,

mastoid processes, zygomatic arches,

spinous processes of C1-C7

• Inferior attachments: manubrium, clavicle, acromion

and spine of the scapula,C7 spinous process,

ligamentum nuchae

Investing layer contd....

• Contents: Majority part except

- Skin

- Subcutaneous vessels

- Sensory nerves


• Splits to enclose both the sternocleidomastoid

and trapezius muscles


• Pretracheal layer- intermediate layer

• Contents:

• Infrahyoid muscles

• Trachea and larynx

• Esophagus

• Recurrent laryngeal nerves

• Superior laryngeal nerves

• Lymph nodes

Pretracheal layer contd...

• Prevertebral fascia

Prevertebral fascia contd...

• Contents:

• 1. Vertebral column-> vertebrae, discs and ligaments,

spinal cord and nerve roots and vessels

• 2. Paravertebral muscles


• Pierced by the four cutaneous branches of

the cervical plexus:

• Greater auricular nerve

• Lesser occipital nerve

• Transverse cervical nerve

• Supraclavicular nerve


Carotid sheath

Classification of neck spaces

Deep Neck Spaces are described in relation to the

Hyoid bone

• Suprahyoid neck

• Infrahyoid neck

• Supra and infrahyoid neck (Entire length of neck)

• Suprahyoid neck spaces

- Buccal space - Masticator space

- Submandibular space - Parotid space

- Sublingual space - Peritonsillar space

- Submental space - Parapharyngeal space

Suprahyoid neck spaces

• Buccal space

• It is located between the buccinator and platysma

muscles

• Contents:

• Fat

• Parotid duct

• Facial and buccal vessels

• Facial nerve: buccal branch

• Trigeminal nerve: buccal branch of the mandibular division

Buccal space contd ...

Submandibular space

It is a U-shaped compartment of the suprahyoid neck

• Includes sublingual and submaxillary, divided by

mylohyoid muscle

Submandibular space contd...

• Contents (Submaxillary space):

• Superficial portion of the submandibular gland

• Submandibular lymph nodes (level 1b)

• Facial artery and vein

• Fat

• Inferior loop of the

hypoglossal nerve

Submandibular space contd...

Sublingual space

• Inverted V with its apex pointing anteriorly and is

located between:

• Tongue musculature superiorly

• Anterior one-third of the mylohyoid

muscle inferolaterally

• Posteriorly-communicates with submandibular and

parapharyngeal spaces. Anteriorly, the two

sublingual spaces are communicating via a small

isthmus just below the frenulum.

Sublingual space contd...

• Contents:

- Sublingual gland and duct

- Lingual nerve

- Lingual artery and vein

- Glossopharyngeal and hypoglossal nerves

- Deep portion of the submandibular gland and duct

Sublingual space contd...

Submental space

• Midline space that lies between the anterior

bellies of the digastric muscles

• Contents: anterior jugular vein, submental lymph

nodes (level 1a)

• Boundaries

• Superiorly: mylohyoid muscle

• Inferiorly: superficial layer of the deep cervical fascia

• Laterally: anterior bellies of the digastric muscles

• Anteriorly: mandible

• Posterior: hyoid bone

Submental space contd...

• Masticator space

• Superficial layer of the deep cervical fascia as it

surrounds the masseter laterally and the pterygoid

muscles medially

• Direct communication with the temporal space

superiorly deep to the zygoma

• Subdivided into superficial and deep spaces by the

body of the temporalis muscle

Masticator space contd...

• Contents:

- Muscles of mastication

- Ramus and body of mandible

- Inferior alveolar nerve

- Inferior alveolar vein and artery

- Mandibular division of the trigeminal nerve (V3)

– enters the masticator space via the foramen ovale


• Masticator space has larger area at skull base and

has Foramen ovale at it’s roof, allowing potential

tumor spread


Parotid space

• Surrounded by the superficial layer of the deep fascia

that sends dense connective tissue septa from the

capsule into the gland

• Contents:

- Parotid glands

- Intraparotid lymph nodes

- Intraparotid facial nerve

- External carotid artery

- Retromandibular vein

Parotid space contd...

Peritonsillar space

• Medially- capsule of the palatine tonsil

• Laterally- superior constrictor

• Superiorly- anterior tonsillar pillar

• Inferiorly- posterior tonsillar pillar

Parapharyngeal space

Parapharyngeal space contd...

Surgical importance

• Directly involved by lateral extension of peritonsillar

abscesses

• Other sites for infections: pharynx, dentition, salivary

glands, nasal infections, or Bezold abscess.

• Medial displacement of the lateral pharyngeal wall

and tonsil is a hallmark of a parapharyngeal space

infection


• Displacement patterns of fat within the

parapharyngeal space will aid in the localisation:

- Parotid space displaces the parapharyngeal fat

anteromedially

- Masticator space displaces the parapharyngeal fat

posteromedially


- Carotid space displaces the parapharyngeal fat

anteriorly

- Retropharyngeal space

and danger space displace

the parapharyngeal fat

anterolaterally

Approaches

Cervical transpharyngeal approach

Infrahyoid neck Spaces

• Anterior cervical space or Pretracheal space

- Enclosed by the middle layer of the deep cervical fascia

- Runs from the thyroid cartilage into the anterior

superior mediastinum to the arch of the aorta

- Below the level of the thyroid gland this space

communicates laterally with the retropharyngeal space

Anterior cervical space contd ...

Posterior cervical space

Supra and infrahyoid neck spaces

- Retropharyngeal space

- Prevertebral space

- Danger space

- Carotid space

• Carotid space:

- Cylindrical space that extends from the skull base to

the aortic arch

- Bifurcation of the common carotid usually occurs at

the boundary of the suprahyoid and infrahyoid space

Carotid space contd...

• Boundaries:

- Superior margin: lower border of jugular foramen

- Inferior margin: aortic arch

- Anterolateral margin: sternocleidomastoid muscle


Retropharyngeal space

- Lies posterior to the pharynx and oesophagus

- Base of the skull to a variable level between the T1

and T6 vertebral bodies

Retropharyngeal space contd...

• Retropharyngeal soft tissue -> 14mm (<15yr)

and -> 22mm in adults is abnormal

Retropharyngeal space contd...

Danger space

Danger space contd...

Axial view of Danger space

Perivertebral space

- Posterior to the retropharyngeal space and danger

space

- Skull base to the upper mediastinum

• Subdivided into:

• Prevertebral portion: anteriorly located

• Paraspinal portion: posteriorly located

Perivertebral space contd...

References

• Scott-Brown’s 7th edition

• Cummings 5th edition

• UTMB

• Radiopaedia

THANK YOU

Surgical anatomy of deep neck spaces

Health & Medicine

Transcript of Surgical anatomy of deep neck spaces