DEEP NECK SPACE

1. DEEP NECK SPACES
BY DR.ANKIT PRAKASH(PGT1)
KIMS,BHUBANESWAR

2. Cervical fascia
Fascia
superficial
deep superficial
middle
deep

3. Superficial fascia
• It is composed of subcutaneous tissue that encircles
neck like a collar
it encircles deep fascia
• Components :-
• Platysma and muscle of facial expression
• Subcutaneous veins nerves and fat
• Superficial lymph nodes
During surgery platysma should be sutured seperately
to prevent adherence of skin to deeper structure to
prevent scarring of skin

4. Deep cervical fascia
Superficial layer/investing layer
Middle layer of deep cervical fascia (pre-tracheal fascia)
Deep layer of deep cervical fascia (prevertebral fascia)
It forms complete collar around neck
Attachments :-
• Skull base, Mandible, hyoid bone, clavicle, sternum, scapula
• Posteriorly:-ligamentum nuchae and cervical spinous process
• It splits to cover SCM and trapezius muscle
Capsule:-
• Parotid
• Submandibular
Spaces:-
• Masticator space
• Parotid space
• Submandibular and sublingual space

5. Superficial layer of deep cervical fascia
Superiorly : attached to the nuchal ridge,
mandible, zygoma, mastoid, and hyoid
bones.
Inferiorly: bounded by clavicles, sternum,
scapula and acromion.
Anteriorly: symphysis menti and hyoid
bone
Posteriorly: ligamentum nuchae and spine
of C7
It invests SCM, trapezius and masseter
and envelops parotid and submaxillary
glands.

6. Superficial layer of deep cervical fascia
This fascia creates 4 spaces:
1. Submental space in the midline
2. Submandibular space laterally
3. Parotid space
4. Masticator space

7. Middle layer of deep cervical fascia
AKA pretracheal fascia
Extend from hyoid bone to superior mediastinum
Contents:-trachea, oesophagus, thyroid, parathyroid gland
,larynx.
Spaces:-pharyngeal mucosal space, retropharyngeal
space, parapharyngeal space, buccal space

8. Deep layer of Deep cervical fascia
• Extent from skull base to T3 vertebra
• Encircles paravertebral and paraspinal muscle ,phrenic
nerve, brachial plexus trunk
• Fuses with anterior longitudinal ligament in posterior
mediastinum and extends laterally as axillary sheath

9. Deep neck spaces
• Our neck is divided into spaces and compartments by
arrangement of layers of superficial and deep layers of
cervical fascia
• They contain loose areolar tissue
• May provide conduit for spread of infection
• it is described in relation to hyoid bone.
 Supra hyoid space
 Infra hyoid space
 Space extending to full length of neck

10. Suprahyoid space
• Submandibular space
• Buccal space
• Masticator space
• Parotid space
• Pharyngeal mucosal space
• Parapharyngeal space

11. INFRAHYOID SPACE
• Visceral space
• Anterior cervical space
• Posterior cervical space

12. Spaces common to both
• Carotid space
• Retropharyngeal space
• Prevertebral space
• Danger space

13. Masticator space
• It is paired suprahyoid cervical space on each side
of the face . Each space is :-
• covered by superficial(investing) layer of deep
cervical fascia.
• The superficial layer of deep cervical fascia
divides into two at the lower border of mandible
The inner layer:-running deep to medial pterygoid
muscle and attaches to skull base medial to foramen
ovale
The outer layer :-it covers masseter and temporalis
muscle and attaches to parietal cavarium superiorly

14. Contents of masticator space
Contents:-
• Muscles of mastication
• Ramus and body of mandible
• Mandibular division of trigeminal nerve
it enters masticator space via foramen ovale

15. Boundaries and relations of masticator space
• Anteriorly:-buccal space
• Posterolaterally:- parotid space
• Medially:-parapharyngeal space
• Inferomedially :-submandibular space
Clinical
Masticator space malignancy can spread to middle
cranial fossa by perineural involvement (mandibular
division of trigeminal nerve )
Related pathologies:-
Masticator space abscess infection of 2nd and 3rd molar
Osteomyelitis
Direct spread of scc
Lymphoma
Minor salivary gland tumors

16. Parotid space
Boundaries:-
Investing fascia (ascending layer of deep cervical
fascia )splitting at angle of mandible-it ecloses parotid
space
Extends
Superiorly to external acoustic meatus
Inferiorly up to mandible
Contents
Parotid gland, proximal part of parotid duct
intra parotid lymphnode
External carotid artery
Retromandibular vein
Parotid gland is divided by facial nerve into
superficial and deep

17. Parotid space
Relations:-
• Lateral to parapharyngeal space
• Medial to superficial space and subcutaneous tissue
• Anterior to carotid space
• Posterior to masticator space
Boundaries :-
This space is circumscribed by superficial layer of deep cervical fascia
Superior margin:-external auditory canal, apex of mastoid process
Inferior margin:-inferior margin of mandible (but can extend further
inferiorly to angle of mandible )
Anterior margin:-masticator space

18. Parotid space
Related pathology :-
• Source of infection is from infection of oral cavity via stenson’s
duct
Any mass originating from parotid space will be centered within
parotid gland
A large mass arising within deep lobe of parotid will medially
displace fat in parapharyngeal space and cause posteromedial
dislocation of posterior belly of digastric muscle and carotid space
Congenital :-
• First branchial cleft cyst
• Cystic hygroma/lymphangioma
• Salivary gland tumor
• Parotid cyst
• Abscess/cellulitis
• Sjogren’s syndrome

19. Parapharyngeal space
It is pyramid shaped space
Base-petrous portion of temporal bone
Apex-at level of hyoid bone
Anterior-pterygo-mandibular raphe
Posterior-pre vertebral fascia
Medial-buccopharyngeal fascia
Lateral-parotid gland,ramus of mandible, medial
pterygoid muscle, fascia covering posterior belly of
digastric muscle
Crossed by styloid process which divides into pre
styloid and post styloid compartment.

20. Parapharyngeal space
Pre styloid compartment:-
• it is anterior to styloid process.
• it contains- fat, deep lobe of parotid gland,connective
tissue ,maxillary artery, inferior alveolar nerve, lingual
nerve and auriculo temporal nerve
Post styloid compartment :-
It is posterior to styloid process
It contains-glossopharyngeal and hypoglossal nerve
,sympathetic chain ,and lymph nodes
Source of infection:-
• Peritonsillar abscess
• Parotid abscess
• Submandibular gland infection

22. parapharyngeal abscess
It is collection of pus in parapharyngeal space .
Causes:-
tonsillitis (acute,chronic)
Peritonsillar abscess, trauma
immuno compromised patients
Causative organism :-
Strep.viridens
Klebsiella
Pseudomonas(ass.with HIV patients )
Present as fluctuant tender swelling in neck
It pushes tonsil medially(bulging is present in lower pole of tonsil)

23. PRESENTING SYMPTOMS OF PARAPHARYNGEAL SPACE LESION
Mostly asymptomatic
Medial displacement of lateral pharyngeal wall
and tonsil is hallmark
Neck & oropharyngeal swelling
Pain
Cranial nerve palsy
Dysphagia , Dyspnea
Trismus, Drooling
ETD
Hoarsness of voice
Hypertension , flushing
Fever

24. parapharyngeal abscess
Drainage:-
Head turned to contralateral side
Incision-4cm in length at 2 finger
below the inferior border of
mandible on affected side

25. Buccal space
Extent:-
Medially-buccinator and maxillary alveolar
ridge
Posterior laterally-masticator space
Contents:-
Buccal fat pad
Related pathology:-
• Parotid duct calculi
• Odontogenic infection
• Minor salivary gland tumors

26. Retropharyngeal space
Extent:-skull base to t4 level/tracheal bifurcation
2 parts :-
Anterior-true retropharyngeal space
Posterior-danger space
Contents:-
SHN-lymph node and fat
IHN-fat
Infection from neck can reach mediastinum through this
pathway

27. Retropharyngeal space
Relations:-
anterior to danger space
Posterior to pharyngeal mucosal space
Anteromedial to carotid space
Posteromedial to parapharyngeal space
Boundaries:-
Anterior margin-middle layer pf deep cervical fascia
Posterior margin-alar fascia
Lateral margin- deep layer of deep cervical fascia
Superior margin-clivus
Inferior margin-the point at which alar fascia fuses with the
middle layer of deep cervical fascia ,typically around T4
vertebral body

28. Retropharyngeal space
Contents
Suprahyoid part:-
Lymph node
• Medial (gets atrophied in adults)
MCC of acute retropharyngeal abscess in children
• Lateral (nodes of rouviere)
pathway for spread of tumors
Pathway for spread of infection
• Extension of infection from parapharyngeal space, parotid or
masticator space
• Oesophageal perforation
• Suppuration of retropharyngeal nodes
Source of infection in danger space :-Infection by rupture of
retropharyngeal abscess

29. Retropharyngeal abscess
It is collection of pus in retropharyngeal space
PPW may be pushed anteriorly
Site of drainage :-
Along posterior border of sternocledomastoid muscle

30. Danger space
Posterior to retropharyngeal space
Bounded by alar fascia anteriorly and prevertebral portion
proper posteriorly
Extends from skull base to diaphragm
Contents-loose areolar tissue which provides easy pathway
for spread of infection
Danger space
At inferior border it is continuous with posterior mediastinum
containing venacava ,arch of aorta, theoracic duct, trachea
and esophagus
erosion of major blood vessel ,lower airway and upper
digestive tract
may cause death of patient

31. Carotid space
It is roughly cylindrical space that extends from skull base to aortic
arch .it is circumscribed by all 3 layers of deep cervical fascia
forming carotid sheath
Lateral to retropharyngeal space
The bifurcation of common carotid usually occurs at boundaries of
suprahyoid and infrahyoid spaces
Relations:-
Suprahyoid carotid space
anteriorly-masticator space ,parapharyngeal space
Laterally-parotid space
Posteriorly-prevertebral space
The suprahyoid portion of carotid space is often synonymous with
post styloid compartment of parapharyngeal space

32. Carotid space
Boundaries :-
Superior margin:-lower border of jugular foramen
Inferior margin:- aortic arch
Anterolateral margin:- sternocledomastoid muscle
Contents :-
• Common carotid artery inferiorly and internal carotid artery superiorly
• Internal juglar vein
• Glossopharyngeal nerve (CN IX) it is anterior to vessel
• Vagus nerve (CN X) it is posterior to posterior notch
• Spinal accessory nerve (CN XI)
• Hypoglossal nerve (CN XII)
• Sympathetic nerves:-medial to vessels and lateral to retropharyngeal
space(behind the sheath )
• Deep cervical lymph node chain

34. Submandibular space
Extent
It extends from myelohyoid superiorly and hyoid bone
inferiorly
Communicates freely with sublingual space
Contents :-
Superficial portion of submandibular gland
Submantle lymph node
Submandibular lymph nodes
Facial artery and veins

35. Submandibular space
Ludwig’s angina :-
It is acute infection of bilateral submandibular and sublingual
spaces and submantle spaces.
Consequence of anterior dental infection
Oedema of floor of mouth and of anterior tongue leads to gross
swelling
Significant risk of life threatening airway obstruction.
Site of drainage
Surgical drainage is done via horizontal incision 2 finger breadth
below the mandibular margin from one angle of the mandible to
the other over the area of induration.

36. Sublingual space
Extent:-
Above myelohyoid muscle
Contents:-
Sublingual gland and their ducts ,lymphnodes, lingual artery and veins
,deeper portion of submandibular gland
RANULA:-
cystic translucent lesion seen in the floor of mouth on one side of the
frenulum and pushing the tongue up.
Arises from sublingual gland due to obstruction of its ducts.

37. Peritonsillar space
Lies between superior constrictor muscle and the tonsillar
capsule.
Clinical:
Infection involving looser areolar tissue causing collection of pus
within the space is called quinsy or peritonsillar abscess.

38. Peritonsillar abscess
It is collection of pus in peritonsillar space
Mostly in young age group (20-30 years)
Causes:-
Acute tonsillitis
Weber’s gland(they are minor salivary gland present in supra tonsillar area)
It may present with
Dysphagia
Referred otalgia(via CN IX)
Neck pain
Site of drainage :-
Should do tonsillectomy 4-6 weeks after drainage

39. REFERANCE-SCOTT BROWN
DHINGRA
CUMMINGS