Surgical anatomy

1. Retropharyngeal space
Dr Safika Zaman, Post graduate trainee,
Dept of ENT & Head-Neck Surgery
VIMS, RKMSP

2. Topic of discussion
• Anatomy & Contents
• Functional anatomy
• Lesions
• Investigation
• Retropharyngeal abscess
• Retropharyngeal lymph nodes
• Retropharyngeal haematoma
• summary

3. Compartments of neck

4. Boundaries
Anterior: buccopharyngeal fascia
Posterior margin: alar fascia.
The anterior space is the "true"
retropharyngeal space.
Posterior space is the danger space .
combined spaces as one functional
unit,
As the fascia is very thin,
radiographical differentiation is not
possible.

5. Boundaries
• Lateral margins: deep
layer of the deep
cervical fascia carotid
and parapharyngeal
space.

6. Boundaries
• Superior: skull base.
• Inferior: fusion of alar
fascia with the middle
layer of the deep cervical
fascia- T4 vertebral body

7. Contents
• areolar fat
• lymph nodes only in the
suprahyoid region (lateral and
medial retropharyngeal)
• small vessels.
Functional importance:
allow free movement of
the pharynx on the
vertebral column during
swallowing, respiration,
speech and exercise.

8. Lesions
• Primary : lipoma, liposarcoma,
synovial sarcoma.
• Direct spread and metastasis:
nasopharyngeal carcinoma,
• SCC of pharyngeal, laryngeal,
sinonasal origin,
• Lymphoma, melanoma,
esthesioneuroblastoma, chordoma,
primary spinal tumour.

9. Fluid collection in retropharyngeal space
• Foreign body ingestion,
• Hematoma, angioedema,
• Retropharyngeal lymphadenitis,
• Vertebral osteomyelitis, Kawasaki
disease,
• Calcific tendinitis of the longus colli
muscle,
• Cystic tumor caused by lymphatic
malformation

10. Investigation
Routine blood investigation
Radiological – X-RAY
CT-Scan
MRI
PET-CT.
FNAC /Biopsy

11. X-RAY(mainly done in retropharyngeal space
infection)
• soft tissue swelling as more than 7
mm at C2 and more than 14 mm at
C6.
• Generally, the anteroposterior
diameter of the prevertebral soft
tissue space in children should not
exceed that of the contiguous
vertebral body.
Image source- medscape

12. Debnam JM, Guha-Thakurta N.
Retropharyngeal and prevertebral spaces:
anatomic imaging and
diagnosis. Otolaryngol Clin North Am.
2012;45(6):1293-1310.
doi:10.1016/j.otc.2012.08.004

13. CT -Scan
• Acute conditions.
• Bone assessment
• Lung assessment
• Less than 1mm slide.

14. CT- Scan of retropharyngeal abscess

15. CT-Scan of RPS Lipoma & ICA

16. CT Scan of nasopharyngeal ca
(a) Axial contrast-enhanced CT shows a large nasopharyngeal carcinoma(star); (b) axial contrast-enhanced
CT shows thickened right RPS (star)extending across the midline;

17. MRI
Tumour extent.
Breech in tissue planes
Lymph node status: size , shape , signal.
Tissue of origin
Involvement of neuro-vascular structures.

18. Normal MRI

19. MRI
AJR 2011; 196:W433–W437
0361–803X/11/1964–W433
© American Roentgen Ray
Society

20. MRI
https://www.wjgnet.com
/1949-
8470/full/v2/i5/159.htm

21. PET-CT
• Neck nodes of unknown primary origin.
• Staging T3 & T4
• Equivocal findings on CT & MRI
• Response to treatments

22. PET - CT
Contrast enhanced CT scan (a)
showing a large right sided
oropharyngeal lesion. PET scan
identified a small FDG-avid
retropharyngeal (RP) lymph
node (arrow) in the
contralateral neck (b) equivocal
on CT alone. This necessitated
delivery of high tumoricidal
doses to the involved
retropharyngeal nodal region
that would have otherwise
received only prophylactic
doses as low-risk elective
volume.
Image source – indian journal of
cancer.

23. FNAC
Du C, Ying H, Zhang Y, Huang Y, Zhai R, Hu C.
Treatment for retropharyngeal metastatic
undifferentiated squamous cell carcinoma from an
unknown primary site: results of a prospective study
with irradiation to nasopharyngeal mucosa plus
bilateral neck. Oncotarget. 2017;8(26):42372-42381
doi:10.18632/oncotarget.16344

24. Biopsy
Patients with
• metastatic neck lymph nodes with
unknown primary
• persistently raised tumour markers a
normal nasopharynx on endoscopy
• inconclusive biopsy results

25. Retropharyngeal abscess
• Early recognition and aggressive
management of RPA are essential
because it still carries significant
morbidity and mortality.
• The mortality rate may be as high as
40-50% in patients in whom serious
complications develop.

26. Etiology of Retropharyngeal abscess
Children
• Nodes atrophy with age
• Suppurative process in lymph
nodes
• Sourse of infection is nose ,
nasopharynx,sinuses,adenoids
Adults
• Usually caused by penetrating
blunt trauma.
• Instrumentation like endoscopy
• Extension of infection from
adjacent spaces.

27. Presentation
• Most of the abscess occurs before
the age of 6.
• Children: fever, irritability, poor oral
intake, neck
lump,torticollis,drooling.
• Adults: sore throat , odynophagia ,
dysphagia, nasal obstruction,
respiratory distress, swelling in
posterior pharyngeal wall.

28. Management of retropharyngeal abscess

29. Management of retropharyngeal abscess
• Key is to protect the airway
• Antibiotic: broad spectrum antibiotics.
• The Sanford Guide to Antimicrobial Therapy recommends adding
empiric vancomycin to the regimen if the patient is in a high-risk
group.
• Vancomycin or linezolid to cover MRSA

30. Management of Retropharyngeal abscess
• Trans-oral drainage – for majority of non complicated
cases. Vertical incision is given on the most fluctuant
point
• Trans-cervical drainage- lateral extension of abscess,
repeat drainage.
• Image guided aspiration.

31. Complication of retropharyngeal abscess
• Airway obstruction
• Mediastinitis
• Pleural involvement
• Epidural abscess
• Sepsis
• Acute respiratory distress syndrome
• Erosion of the second and third
cervical vertebrae

32. Complication of retropharyngeal abscess
• Cranial nerve deficits (IX-XII)
• Septic thrombosis of jugular
vein or hemorrhage
secondary to erosion into
carotid artery.
• Compression of carotid
artery and internal jugular
vein
• Facial nerve palsy

33. Retropharyngeal lymph nodes
Image source-Wiki

34. Retropharyngeal lymph nodes
Primary sites:
• carcinoma of head and neck
• thyroid cancer
• oesophagus cancer
Most frequent metastasis is from nasopharyngeal cancer.
FNA with the guidance of ultrasound, CT or MRI was utilized to obtain
histological diagnosis of retropharyngeal masses.

35. Retropharyngeal lymph nodes in
Nasopharyngeal ca
• RPLN are involved early in nasopharyngeal
cancer, because they are primary draining
LN of nasopharynx.
• Only 5% of patients may suffer from
isolated nodal failure.
• Persistent nodal diseases : Patients who
have persistently enlarged neck nodes 3
months after completion of radiotherapy.

36. Retropharyngeal lymph nodes in
Nasopharyngeal ca
• Primary therapy is IMRT.
• Brachytherapy techniques: can be used for
treatment of nodal failure in conjunction
with surgical resection of the nodal
metastasis.
• Radical neck dissection is considered as
the standard of care for management of
nodal failures.

37. Retropharyngeal hematoma
• In patients with cervical spine trauma it is possible for a hematoma
to form in RP.
• Usually presents with progressive dyspnoea.
• Can be a life threatening emergency
• Other than acute trauma retropharyngeal hematomas related with
anticoagulant therapy,
iatrogenic injury,
infections, foreign body ingestion.
post spinal cord surgery

38. Retropharyngeal hematoma
• Detected with CT Scan or MRI.
• Management is conservative, if large
enough may require tracheostomy &
surgical drainage.
Park JH, Jeong EK, Kang DH, Jeon SR. Surgical Treatment of a
Life-Threatening Large Retropharyngeal Hematoma after Minor
Trauma : Two Case Reports and a Literature Review. J Korean
Neurosurg Soc. 2015;58(3):304-307.
doi:10.3340/jkns.2015.58.3.304

39. Retropharyngeal hematoma
Vertebral artery ruptures
manifesting as hoarseness
Chih-Jen Yanga, Sheng-Yao
Chengb, Cheng-Chung Chengc,
Chi-Tun Tangd, Shih-Hung Tsaia,

40. summary
Potential space.
Surrounded by vital structures
May be a route of spread of infection.
Early involvement in nasopharyngeal cancer.
Trauma may happen during endoscopic or blunt procedures.
Haematoma may form after neck trauma.
Accurate and timely intervention will prevent complication.
Also a route for surgical approach for spinal surgery.

41. Thank you