Cervical Fascia Superficial Layer of the Deep Cervical Fascia (rule of two’s) Muscles Sternocleidomastoid Trapezius Glands Submandibular Parotid Spaces Posterior Triangle Suprasternal space of Burns
Cervical Fascia Middle Layer of the Deep Cervical Fascia Muscular Division Infrahyoid Strap Muscles Visceral Division Pharynx, Larynx, Esophagus, Trachea, Thyroid Buccopharyngeal Fascia
Cervical Fascia Deep Layer of Deep Cervical Fascia Alar Layer Posterior to visceral layer of middle fascia Anterior to prevertebral layer Prevertebral Layer Vertebral bodies Deep muscles of the neck
Cervical Fascia Carotid Sheath Formed by all three layers of deep fascia Contains carotid artery, internal jugular vein, and vagus nerve “Lincoln’s Highway”
Deep Neck Spaces Described in relation to the hyoid Entire length of the neck Suprahyoid Infrahyoid
Deep Neck Spaces Entire Length of Neck: Superficial Space Surrounds platysma Contains areolar tissue, nodes, nerves and vessels Involved with cellulitis and superficial abscesses
Deep Neck Spaces Entire Length of Neck: 1.Retropharyngeal Space Posterior to pharynx and esophagus Anterior to alar layer of deep fascia Extends from skull base to T1-T2
Deep Neck Spaces Entire Length of Neck: 2.Danger Space Anterior border is alar layer of deep fascia Posterior border is prevertebral layer Extends from skull base to diaphragm and is so named because it contains loose areolar tissue and offers little resistance to the spread of infection.
Deep Neck Spaces Entire Length of Neck: 3.Prevertebral Space Anterior border is prevertebral fascia Posterior border is vertebral bodies,ALL and deep neck muscles Extends along entire length of vertebral column. Infection in this space tends to stay somewhat localized due to the dense fibrous attachments between the fascia and the deep muscles.
Deep Neck Spaces Entire Length of Neck: 4.Visceral Vascular Space Carotid Sheath Like the prevertebral space the visceral vascular space is quite compact, contains little areolar tissue and is resistant to the spread of infection. It is termed the “Lincolin’s highway” of the neck . It extends from the base of skull into the mediastinum and because it receives contributions from all three layers of deep fascia it can become secondarily involved by infection in any other deep neck space by direct spread.
Deep Neck Spaces Suprahyoid: 1.Submandibular Space Anterior/Lateral— mandible Superior—mucosa Inferior—superficial layer of deep fascia Posterior/Inferior--hyoid
Deep Neck Spaces Suprahyoid: Submandibular Space comprises Sublingual Space Areolar tissue Hypoglossal and lingual nerves Sublingual gland Wharton’s duct Submylohyoid Space Anterior bellies of digastrics Submandibular gland (These two subdivisions freely communicate around the posterior border of the mylohyoid. )
Deep Neck Spaces Suprahyoid: 2.Parapharyngeal Space (pharyngomaxillary space ) Superior—skull base-petrous portion of temporal bone vs. sphenoid Inferior—hyoid Anterior—ptyergomandibular raphe Posterior—prevertebral fascia Medial—buccopharyngeal fascia Lateral—superficial layer of deep fascia,medial pterygoid and parotid . The parapharyngeal space communicates with submandibular , retropharyngeal, parotid and masticator spaces with important implications in spread of infection .
Deep Neck Spaces Suprahyoid: Parapharyngeal Space comprises: Prestyloid Medial—tonsillar fossa Lateral—medial pterygoid Contains fat, connective tissue, nodes Poststyloid Carotid sheath Cranial nerves IX, X, XII The stylopharyngeal aponeurosis of Zuckerkandel is formed by the intersection of the alar, buccopharyngeal and stylomuscular fascia and acts as a barrier to the spread of infection from the prestyloid compartment to the poststyloid compartment.
Relations to other spaces Normal anatomy of parapharyngeal space. BS = buccal space, ICA = internal carotid artery, IJV = internal jugular vein, MS = masticator space, PMS = pharyngeal mucosal space, PPS = parapharyngeal space, PS = parotid space, PVS = prevertebral space, RPS = retropharyngeal space, SMS = submandibular space, T = torus tubarius. Axial schematic at nasopharynx level shows that parapharyngeal space is divided into prestyloid and poststyloid compartments by tensor-vascular-styloid fascia connecting tensor veli palatini muscle with styloid process.
Deep Neck Spaces Suprahyoid: Peritonsillar Space Medial—capsule of palatine tonsil Lateral—superior pharyngeal constrictor Superior—anterior tonsil pillar Inferior—posterior tonsil pillar. This space contains loose areolar tissue, primarily in the area adjacent to the soft palate, which explains why the majority of peritonsillar abscesses will localize to the superior pole of the tonsil.
Deep Neck Spaces Suprahyoid:3.Masticator and Temporal Spaces Formed by the superficial layer of deep cervical fascia and contains. Masseter and pterygoids Temporalis. The masticator space is in direct communication with the temporal space superiorly deep to the zygoma. The temporal space has as its lateral boundary the superficial layer of deep fascia and its medial boundary the periosteum of the temporal bone. It is subdivided into superficial and deep spaces by the body of the temporalis muscle. This space contains the internal maxillary artery and the mandibular nerve.
Deep Neck Spaces Suprahyoid:4. Parotid Space Formed by superficial layer of deep fascia and dense septa from capsule into gland. In addition to the parotid gland, this space contains the parotid lymph nodes, the facial nerve and posterior facial vein. The fascial envelope is deficient on the supero- medial surface of the gland, facilitating direct communication between this space and the parapharyngeal space.
Deep Neck Spaces Infrahyoid: Anterior Visceral Space Formed by middle layer of deep fascia Contains thyroid, trachea, esophagus. This potential space 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 .
Pathophysiology Deep neck space infections can arise from a multitude of causes., as follows:1. Spread of infection can be from the oral cavity, face, or superficial neck to the deep neck space via the lymphatic system.2. Lymphadenopathy may lead to suppuration and finally focal abscess formation.3. Infection can spread among the deep neck spaces by the paths of communication between spaces.4. Direct infection may occur by penetrating trauma.
Spread of infection Tonsillitis may lead to peritonsillar abscess. If not treated successfully, peritonsillar abscess may spread to the lateral pharyngeal space. From thereto the posterior pharyngeal and prevertebral spaces and into the chest. Mediastinitis and empyema may ensue. Alternatively, infection may spread from the lateral pharyngeal space to the contents of the carotid sheath, leading to internal jugular vein thrombosis, subacute bacterial endocarditis, pulmonary emboli, carotid artery thrombosis cerebrovascular insufficiency, Horner syndrome ,or may cause even airway obstruction .
Retropharyngeal Abscess 50% occur in patients 6-12 months of age 96% occur before 6 years of age Retropharyngeal phlegmon. Axial CT section through the lower nasopharynx shows a well-marginated lucent area in the retropharyngeal/parapharynge al space with an enhancing wall and surrounding edema
Adults Pediatrics Cause—trauma, Cause—suppurative instrumentation, process in lymph nodes extension from Nose, adenoids, adjoining deep neck nasopharynx, sinuses space
Danger Space Cause—extension from retropharyngeal, prevertebral or parapharyngeal space Can extend to mediastinum .
Prevertebral Space Back, shoulder, neck pain made worse by deglutition Dysphagia or dyspnea Cause—Pott’s abscess, trauma, osteomyelitis, extension from retropharyngeal and danger spaces
Visceral Vascular Space Induration and tenderness over SCM Torticollis toward opposite side Spiking fevers, sepsis Cause—intravenous drug abuse, extension from other deep neck spaces
Submandibular Space Anterior neck swelling, floor of mouth edema Cause—70-85% have odontogenic origin First molar and anterior Second and third molars Sialadenitis, lymphadenitis, mandible fractures,etc. Right submandibular gland infection with a stone
Which space is affected ? The apex of the first molar is above the mylohyoid, so involvement of this tooth, or teeth anterior to this, will first involve the sublingual space. In contrast, the apices of the second and third molars are below the mylohyoid and infection here will first spread to the submylohyoid space. However, as previously mentioned, these spaces freely communicate around the posterior border of the mylohyoid, and both subspaces may be involved.
Ludwig’s angina Tender, firm anterior neck edema without fluctuanceContrast CT scan through the tongue and oral cavitydemonstrates an enhancing inflammatory mass with abscessin the right tongue and oral cavity with extension into theparapharyngeal space and masticator space.
Ludwigs angina. Axial CT section through the tongue demonstrates diffuse enlargement of the tongue associated with low attenuation areas consistent with phlegmon.
Parapharyngeal Space Cause—infection of pharynx, tonsil, adenoids, dentition, parotid, mastoid, suppurative lymphadenitis, extension from other deep neck spaces
Middle ear infections or mastoiditis may involve the parapharyngeal space after rupture of a Bezold’s abscess on the inner aspect of the mastoid tip along the digastric ridge. . Bezolds abscess, upper left neck. A, Axial noncontrast CT section defines an ill-defined mass in the upper posterior left neck. B, Axial CT section (bone window setting) demonstrates lytic destruction in the lower left mastoid secondary to coalescent mastoiditis.
Peritonsillar Space Fever, malaise “Hot-potato” voice, trismus. Cause—extension from tonsillitis. These infections are uncommon in the pediatric population, but instead tend to effect post-pubescent individuals. CT section demonstrates an enhancing mass in the right peritonsillar region with a low- attenuation area centrally consistent with an abscess cavity
Masticator Temporal Space Swelling along ramus of mandible Parotid Space Cause— Medial bulge odontogenic, from of posterior third molars lateral pharyngeal wall Cause— parotitis, sialolithiasis, Sjogren’s syndrome
Right neck abscess with extension to the masticator space
Internal Jugular Vein Thrombosis Complications Lemierre’s syndrome F/C, prostration, swelling and pain along SCM Bacteremia, septic embolization, dural sinus thrombosis Pulmonary embolism occurs in up to 5% of these patients. Patients that develop deep neck infection secondary to intravenous drug abuse.Right jugular vein thrombosis. Axial CTsection through the neck below the angleof the mandible demonstrates a lowattenuation area with an enhancementwall in the right neck medial to theindistinct and enlargedsternocleidomastoid muscle.
Complications Carotid Artery Rupture Mortality of 20-40% Sentinel bleeds from ear, nose, mouth Majority from internal carotid, less from external carotid, and fewest from common carotid
Complications Mediastinitis A- MDCT of the neck shows two large fluid collections containing gas in both the submandibular spaces (arrows).(B) At the level of the hyoid bone, a large fluid collection is seen in the visceral space (C) Large fluid collection in the visceral space (D) The fluid collection spreads to the anterior mediastinum (E) Sagittal multiplanar reformatted CT image shows spread of descending necrotizing mediastinitis
Special Consideration Recurrent Deep Neck Space Infection THINK CONGENITAL ABNORMALITY Nusbaum, et al: 12 cases of recurrent deep neck infection Most Common: second branchial cleft cyst Others: first, third, fourth branchial cleft cysts, lymphangiomas, thyroglossal duct cysts, cervical thymic cyst Infected right branchial cleft cyst. CT scan shows an oval-shaped lucent area in the right neck at the level of the upper thyroid cartilage