Neck spaces radiology

1. ANATOMY OF NECK
SPACES AND LEVELS OF
CERVICAL LYMPH NODES
BY DR. WALID REZK, M.D.
LECTURER OF RADIODIAGNOSIS

2. INTR0DUCTION
▶ Basis for dividing neck into spaces and compartments :
arrangement of superficial and deep layers of cervical fascia
▶ The importance of this spaces is that they may limit to some degree the
spread of most infections and some tumors
▶ A proper understanding of their anatomy will also aid in the diagnosis of
various conditions

3. CERVICAL FASCIAE
Fascia
Superficial
Deep
Superficial
Middle
Deep

4. Cervical fascial planes

5. NECK SPACES
Described in relation to the hyoid bone.
▶ Suprahyoid Spaces.
▶ Infrahyoid Spaces.
▶ Spaces extending up to the entire length of the neck.

6. Spaces extending up to the entire length of the
neck:
▶ Carotid Space.
▶ Retropharyngeal Space.
▶ Danger space.
▶ Peri-vertebral Space (prevertebral component & para-spinal component) .

7. SUPRAHYOID SPACES
▶ Sublingual Space.
▶ Submandibular Space.
▶ Buccal Space.
▶ Masticator Space.
▶ Parotid Space.
▶ Pharyngeal mucosal Space.
▶ Parapharyngeal Space

9. INFRAHYOID SPACES
▶ Visceral Space.
▶ Anterior cervical
Space.
▶ Posterior cervical
Space.

13. Retropharyngeal Space
▶ The retropharyngeal space is posterior to the pharynx and oesophagus,
and extends from the base of the skull to a variable level between the T1
and T6 vertebral bodies 2.
▶ Between middle layer deep layer of deep cervical fascia.
▶ The main component of the retropharyngeal space is areolar fat.
▶ Lymph nodes are found in the portion of the retropharyngeal space above
the hyoid bone, and these lymph nodes drain the pharynx, nasal cavity,
paranasal sinuses and middle ears. These lymph nodes are prominent in
children, and atrophy with age.
▶ pathway for spread of infections / tumors into the mediastinum from the
neck.
▶ http://radiopaedia.org/articles/retropharyngeal-space

14. Relations
▶ The retropharyngeal space is:
 anterior to the danger space
 posterior to the pharyngeal
mucosal space
 anteromedial to the carotid space
 posteromedial to the
parapharyngeal space

15. Retropharyngeal space
▶ Lateral soft tissue X-ray (extension, inspiration) abnormal findings:
1. C2-post pharyngeal soft tissue >7mm
2. C6–adults >22mm, peads >14mm
3. STS of post pharyngeal region >50% width of vertebral body

16. DANGER SPACE
▶ Posterior to the RPS.
▶ Bounded by the Alar fascia anteriorly and Prevertebral portion proper posteriorly.
▶ Extends from the skull base up to the diaphragm.
▶ Content : loose areolar tissue which provides easy pathway for the spread of infections.
▶ In healthy patients, it is indistinguishable from the retropharyngeal space. It is only
visible when distended by fluid or pus, below the level of T1-T6, since the
retropharyngeal space variably ends at this level.

18. PERIVERTEBRAL SPACE
▶ Posterior midline space of SHN and
IHN
▶ The perivertebral space is a
cylinder of soft tissue lying posterior
to the retropharyngeal space and
danger space surrounded by the
prevertebral layer of the deep
cervical fascia.
▶ Extent : base of skull to level of
coccyx
http://radiopaedia.org/articles/periverte
bral-space

19. ▶ The deep cervical fascia sends a deep slip to the to the transverse
process which subdivides the space into:
• prevertebral portion: anteriorly located
• paraspinal portion: posteriorly located
▶ Contents:
o prevertebral portion:
 cervical vertebral body and disc
 prevertebral muscles: longus colli and capiti
 scalene msucles
 vertebral artery and vein
 phrenic nerve
 brachial plexus
o paraspinal portion:
 posterior elements of cervical vertebrae
 paraspinal muscles

20. Boundaries:
▶ anterior: danger space and retropharyngeal space
▶ posterior: fascia attaches to spinous process and ligamentum nuchae
▶ lateral: surrounded by posterior cervical space
▶ superior: base of skull
▶ inferior: the perivertebral space extends to the level of the coccyx

22. CAROTID SPACE
▶ Paired tubular structure traversing SHN
and IHN
▶ Skull base to superior mediastinum
▶ Lateral to RPS
▶ Enveloped by carotid sheath : all 3
layers of DCf
▶ Contents : SHN – ICA IJV , CN9-12,
:IHN - CCA, IJV , CN10 trunk (
vagus)
▶ The bifurcation of the common carotid
usually occurs at the boundary of the
suprahyoid and infrahyoid spaces
http://radiopaedia.org/articles/carotid-space

23. CAROTID SPACE

24. CAROTID SPACE
IHN
SHN

25. CAROTID SPACE

27. MASTICATOR SPACE
▶ The masticator space are paired suprahyoid cervical spaces on each
side of the face. Each space is enveloped by the superficial (investing)
layer of the deep cervical fascia.
▶ The superficial layer of deep cervical fascia splits into two at the lower
border of the mandible, the inner layer running deep to the medial
pterygoid muscle and attaches to the skull base medial to foramen ovale
and the outer layer covering masseter and temporalis muscles and
attaches to the parietal cavarium superiorly.

29. ▶ Extends from skull base to the inferior edge of the mandible.
▶ 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
▶ Boundaries and relations
• anteriorly: buccal space
• posterolaterally: parotid space
• medially: parapharyngeal space
▶ Communications
• Masticator space malignancy can spread perineurally via the
mandibular division of the trigeminal nerve into the middle cranial
fossa.

30. MASTICATOR SPACE
M
T
L

31. PAROTID SPACE
▶ Boundary : Investing fascia(SLDCF) splitting at the angle of mandible.
▶ Extends : Superiorly external acoustic meatus
Inferiorly up to the mandible.
▶ Contents: Parotid Gland, proximal part of the parotid duct, intraparotid lymph
nodes and vessels.
▶ Parotid gland is divided by facial nerve into superficial and deep.
▶ Division identified on imaging by retromandibular vein.
▶ http://radiopaedia.org/articles/parotid-space

32. ▶ Relations
• lateral to the parapharyngeal space 1
• medial to superficial space and subcutaneous tissue
• anterior to the carotid space
• posterior to the masticator space

33. PAROTID SPACE

34. PAROTID SPACE

35. BUCCAL SPACE
▶ The buccal spaces are paired fat contained spaces on
each side of the face forming cheeks. Each space is
enveloped by the superficial (investing) layer of the deep
cervical fascia.
▶ Contents
• fat: cheek padding
• parotid duct
• accessory parotid gland in 20% of people which can
cause facial asymmetry; readily seen on MRI
• facial and buccal arteries and corresponding veins
• facial nerve (CN VII): buccal branch
• trigeminal nerve (CN V): buccal branch of the
mandibular division (CN Vc)
▶ http://radiopaedia.org/articles/buccal-space

36. ▶ Boundaries and relations
• anterior: orbicular oris muscles and the angle of the mouth
• posterior: masseter muscle, mandible, medial pterygoid and lateral
pterygoid muscles
• superior: zygomatic process of the maxilla and zygomaticus muscles
• inferior: depressor anguli oris muscle and the deep fascia attaching to
the mandible
• medial (deep): buccinator muscle
• lateral (superficial): platysma muscle and subcutaneous tissues with
the skin

37. BUCCAL SPACE

38. SUBMANDIBULAR SPACE
▶ Extend : Mylohoid superiorly & hyoid
bone inferiorly.
▶ Communicates freely with sublingual
space.
▶ Contents : superficial portions of the
Submandibular gland, submental and
submandibular LNs, facial artery and
vein, fat and ant belly of digastric.

39. SUBMANDIBULAR SPACE

41. SUBLINGUAL SPACE
Extent : Above the mylohyoid muscle
Contents : Sublingual gland and their ducts , LNs, hypoglossal muscle , lingual
artery and vein , hypoglossal N and deeper portion of submandibular gland.

43. SUBLINGUAL SPACE

44. PHARYNGEAL MUCOSAL SPACE
▶ The pharyngeal mucosal space is the most internal compartment (closest
to the airway) of the seven deep compartments of the head and neck,
delineated by the middle (pretracheal) layer of deep cervical fascia . It
extends from the base of the skull to the cricoid cartilage.
▶ http://radiopaedia.org/articles/pharyngeal-mucosal-space-1

45. ▶ Contents
• squamous mucosa
• lymphoid tissue belonging to the pharyngeal lymphoid ring
(Waldeyer's ring)
• minor salivary glands
• cartilaginous portion of the Eustachean tube
• superior pharyngeal constrictor
• middle pharyngeal constrictor
• levator palatini
▶ Relations
• medial to the parapharyngeal space
• anterior to the retropharyngeal space

46. PHARYNGEAL
MUCOSAL SPACE

47. PARAPHARYNGEAL SPACE
▶ The parapharyngeal space is shaped like
a pyramid, inverted with its base at the
skull base, with its apex inferiorly
pointing to the greater cornu of the hyoid
bone.
▶ Contents
• fat (main component)
• trigeminal nerve (CN V)
• internal maxillary artery
• ascending pharyngeal artery
• pterygoid venous plexus only small
portion; mainly within masticator
space
• contains no lymph nodes or salivary
glands

48. ▶ Relations
• medial to the masticator space
• lateral to the pharyngeal mucosal space
• anterior to the prevertebral space
• posterior to the medial pterygoid
▶ http://radiopaedia.org/articles/parapharyngeal-
space

49. PARAPHARYNGEAL SPACE

50. Visceral space
▶ The visceral space extends from the hyoid bone to the superior
mediastinum (level of aortic arch / T4), and is surrounded by the middle layers
of the deep cervical fascia.
▶ Extend from hyoid bone to superior mediastinum
▶ Contents
• thyroid gland
• parathyroid gland
• oesophagus
• larynx
• hypopharynx
• trachea
• recurrent laryngeal nerve
• lymph nodes (level VI)

52. CERVICAL SPACES
ANTERIOR CERVICAL SPACE : Hyoid to clavicle
▶ Anterior cervical space is continuous with the submandibular space
and lateral to the visceral space.
▶ Content : Only fat
POSTERIOR CERVICAL SPACE : Extend from the skull base to the clavicles.
▶ Deep and posterior to sternocledomastoid
▶ Content : fat, spinal accessory nerves and spinal accessory chain of deep cervical lymph
nodes.

53. CERVICAL SPACES

54. CERVICAL SPACES

56. Thyroid gland
56

57. ▶ The thyroid gland consists of two lateral lobes joined by a midline isthmus, and
lies anterior and lateral to the trachea.
▶ The lobes extend from the thyroid cartilage superiorly to the sixth tracheal ring
inferiorly
▶ Posterolaterally are the neck vessels, Behind these, on either side, are the
prevertebral muscles
▶ Anterior to the gland are the strap muscles of the neck and the sternomastoid
muscles
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66. Larynx
66

67. ▶ The larynx extends from the base of the tongue to the trachea, lying
anterior to the third to sixth cervical vertebrae.
▶ Its framework is composed of three single and three paired cartilages,
which articulate with each other
▶ the cricoid cartilage: shaped like a signet ring, with a flat, wide lamina
posteriorly and an arch anteriorly.
▶ It is joined to the thyroid cartilage above by the cricothyroid
membrane,
▶ The paired pyramidal arytenoid cartilages sit on the superolateral
margin of the signet posteriorly.
67

68. ▶ These bear anteroinferior vocal processes, which give rise to the
vocal ligaments of the true vocal cords.
▶ The thyroid cartilage forms anterior and lateral boundary of the
larynx.
▶ It is formed by a pair of laminae, which are joined anteriorly
forming an angle and are separated above to form the superior
thyroid notch.
▶ The posterior parts of the laminae have upper and lower
projections known as the superior and inferior horns or
cornua.
▶ The inferior horns articulate with the signet of the cricoid
cartilage.

69. 69

70. ▶ The epiglottis is a leaf-shaped cartilage whose narrow base
is attached to the inner surface of the thyroid cartilage
▶ It projects up behind the base of the tongue and directs boluses
laterally into the piriform fossae during deglutition, thus protecting
the larynx.
▶ Three mucosal folds, the glossoepiglottic folds - namely, a
central and two lateral folds - pass from the anterior surface of
the epiglottis to the base of the tongue. These form paired
recesses between the base of the tongue and the epiglottis
known as the valleculae.
▶ A further pair of mucosal folds pass from the lateral margin of the
epiglottis posteriorly to the arytenoid cartilages separating the
larynx from the piriform fossae. These are the aryepiglottic folds
which, together with the epiglottis, define the entrance to the
larynx.
▶ The cavity of the larynx is divided into three parts by upper and
lower pairs of mucosal folds. The upper pair of folds are the false
cords. The space between the laryngeal entrance and the false
cords is known as the vestibule or the sinus of the larynx.
▶ The lower pair of folds are the true cords and contain the vocal
ligaments, which are responsible for voice production. The space
between the false and true vocal cords is the laryngeal ventricle.
70

71. Cross-sectional anatomy of the
larynx
Supraglottic level
▶ The larynx is anterior to the piriform
sinuses, separated from them by the
aryepiglottic folds.
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74. Glottic level
▶ A complete ring of cartilage is seen at this level –thyroid cartilage anteriorly
& lamina of the cricoid &arytenoid cartilages posteriorly.
▶ The anterior fusion of the vocal cords is known as the anterior commissure
and is very thin when the cords are abducted. Similarly, the posterior
commissure, which is seen between the arytenoids
▶ The larynx is elliptical in shape at the level of the true cords and triangular at
the level of the false cords, which are at a slightly higher level.
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75. 75

76. Infraglottic level
▶ Just below the cords the larynx is elliptical. The lamina of the cricoid is
posterior, with the cricothyroid membrane anterior.
▶ At a lower level the larynx is more circular and the cricoid forms a complete
ring. Part of the lobes of the thyroid gland may be seen laterally,
76

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SG 1 (V)

80. 80

81. SG2 (AEF) 81

82. 82

83. SG3 (FVF) 83

84. G 84

85. IG1 85

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99. Cervical trachea and esophagus
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107. CT

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117. MRI

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127. LEVELS OF CERVICAL LYMPH
NODES

128. Deep Lymph Nodes
1. Submental
2. Submandibular (Submaxillary)
Anterior Cervical Lymph Nodes (Deep)
3. Prelaryngeal
4. Thyroid
5. Pretracheal
6. Paratracheal
Deep Cervical Lymph Nodes
7. Lateral jugular
8. Anterior jugular
9. Jugulodigastric
Inferior Deep Cervical Lymph Nodes
10. Juguloomohyoid
11. Supraclavicular (scalene

130. Level I
Submental and submandibular nodes
Level I A
Submental nodes, between the medial margins of the anterior
bellies of the digastric muscles.
Level I B
Submandibular nodes, lateral to level I A nodes and anterior to the
back of the submandibular salivary gland.

132. Level II
Upper internal jugular nodes, posterior to the back of the submandibular
salivary gland, anterior to the back of the sternocleidomastoid muscle and
above the level of the bottom of the body of the hyoid bone.

134. Level III
Middle jugular nodes, between the level of the bottom of the body of the
hyoid bone and the level of the bottom of the cricoid arch, anterior to the back
of the sternocleidomastoid muscle.

136. Level IV
Low jugular nodes, between the level of the bottom of the cricoid arch and
the level of the clavicle, anterior to a line connecting the back of the
sternocleidomastoid muscle and the posterolateral margin of the anterior
scalene muscles; they are lateral to the carotid arteries.

138. Level V
Posterior triangle nodes, posterior to the back of the sternocleidomastoid
muscle, and posterior to the line described in level IV.
▶ Level V AAbove the level of the bottom of the cricoid arch.
▶ Level V B Between the level of the bottom of the cricoid arch and the level
of the clavicle

140. Level VI
Upper visceral nodes, between the carotid arteries from the level of the
bottom of the body of the hyoid bone to the level of the top of manubrium.

142. 142