The document discusses the fascia, spaces, and lymphatic drainage of the neck. It defines the different fascial layers of the neck and explains the importance of fascial spaces in localizing infections. It then classifies and describes the boundaries and contents of the major deep neck spaces, including the parapharyngeal, retropharyngeal, submandibular, and danger spaces. Finally, it discusses the classification of lymph node levels in the neck according to the Memorial Sloan Kettering system and lists the different nodal levels.

1. Fascia , spaces and
Lymphatic drainage of Neck
Dr. Krishna Koirala
MBBS, MS (ENT-HNS)
15-06-2020

2. Questions:
• Write down different fascial coverings of neck. What is the
significance of fascial spaces of neck?
• Classify deep neck spaces. Write down the boundaries and
contents of parapharyngeal/ retropharyngeal/ submandibular
space. What is danger space?
• How are deep neck spaces classified ? Write down the
subdivisions and contents of Submandibular space.
• Which classification is used to classify the different nodal
levels of neck ? List the different nodal levels of neck. What is
Rouvier’s/ Delphian lymph node ?

3. • Neck : Area between the lower border of mandible
above and suprasternal notch and clavicle below
• Complex region :
− Passageway for communication between head and
rest of the body
• Contains vital structures : larynx, trachea, esophagus,
great vessels, cranial nerves, sympathetic trunk,
spinal cord

4. Fascia and fascial spaces of Neck
• Importance
− Help in localization of neck space infections
thereby stopping the spread of infection to other
areas for a relatively longer time
− Dissection is easier, better controlled and more
bloodless if it proceeds along the fascial planes

5. • Skin
– Contains constant natural lines of cleavage
horizontally
– Incision along the cleavage line gives narrow scar
• Superficial fascia
− Thin layer that encloses platysma, cutaneous
nerves, superficial veins, superficial lymph nodes
• Deep fascia

6. Deep fascia Contains 3 layers
• Investing layer
– Splits to surround
trapezius and
sternomastoid muscle
– Forms sheaths to
parotid and
submandibular gland ,
carotid sheath and
cranial nerves

7. • Middle layer (Two subdivisions)
− Muscular : surrounds the infrahyoid strap muscles
− Visceral : envelops the pharynx, larynx, esophagus, trachea,
and thyroid gland
• Deep Layer (Prevertebral fascia)
− Surrounds deep muscles of neck
− Cervical sympathetic trunk lies superficial to fascia
− Cervical plexus, phrenic nerve and brachial plexus lie
deep to fascia

9. Deep Neck Spaces
(Classified in relation to the hyoid bone)
• Those traverse the entire length of the neck
– Retropharyngeal space, danger space, prevertebral
space, visceral vascular space (carotid sheath)
• Suprahyoid
− Submandibular, parapharyngeal, peritonsillar ,
masticator, parotid, temporal space
• Infrahyoid
– Anterior visceral space

10. Parapharyngeal Space
• Boundaries
− Base and superior limit - Skull Base
− Apex – Lesser cornu of hyoid
− Lateral – Ascending ramus of mandible, Medial Pterygoid,
Parotid fascia and gland
− Medial – Buccopharyngeal fascia
− Anterior - Pterygomandibular raphe
− Posterior - Prevertebral fascia
− Inferior - Fascia lateral to angle of mandible

12. Parapharyngeal Space

13. • Subdivisions by tensor- vascular styloid fascia into two
compartments
• Prestyloid compartment :
– Retromandibular portion of deep lobe of the parotid gland,
adipose tissue, lymph nodes associated with the parotid
gland
• Poststyloid compartment :
– Internal carotid artery, internal jugular vein, CNS IX- XII,
sympathetic chain, lymph nodes

14. Retropharyngeal space
• Immediately posterior to the nasopharynx,
oropharynx, hypopharynx, larynx, and trachea
• Boundaries
– Buccopharyngeal fascia anteriorly
– Alar fascia posteriorly
– Carotid sheath and parapharyngeal space laterally
– Base of the skull superiorly
– Inferiorly to the mediastinum at the level of the
tracheal bifurcation

15. • Divided into two lateral compartments (space of
Gillette) by a fibrous raphe
• Each lateral compartment contains retropharyngeal
nodes which usually disappear after 4-5 years of age
• Communicates with the parapharyngeal space and
the posterior mediastinum leading to spread of
infection to these areas

16. • Danger space
− Formed anteriorly by the alar fascia and
posteriorly by the prevertebral fascia
− Extends down the mediastinum to the level of the
diaphragm
• Prevertebral space
– Bounded anteriorly by the prevertebral fascia and
posteriorly by the longus coli muscles of the spine
– Continues to the insertion of the psoas muscles

18. Submandibular space
• Boundaries
– Inferior : superficial layer of the deep cervical
fascia extending from hyoid to the mandible
– Lateral : body of the mandible
– Superior : mucosa of the floor of mouth

19. Subdivisions
• Divided by the myelohyoid muscle into
• Sublingual space ( Supramyelohyoid)
– Contains sublingual gland, hypoglossal nerve and
Wharton’s duct
– Continuous with the submaxillary space via the
posterior margin of the myelohyoid muscle
• Submaxillary space ( Inframyelohyoid)

22. Triangles of Neck

23. Anterior triangle
• Anteriorly - midline of neck
• Posteriorly - anterior border of Sternocleidomastoid
• Superiorly - lower border of mandible
• Floor - myelohyoid, hyoglossus
• Subdivided by bellies of digastric and omohyoid
muscles into submental, submandibular, carotid,
muscular triangles

25. • Chief contents of anterior triangle
− Common carotid , external and internal carotid
arteries
− Internal jugular vein
− Vagus and recurrent laryngeal nerves
− Submandibular gland
− Lymphatic tissue

26. Posterior Triangle
• Anteriorly by posterior border of SCM
• Posteriorly by trapezius
• Inferiorly - middle 3rd of clavicle
• Floor - deep layer of deep cervical fascia
• Roof - superficial layer of deep cervical fascia
• Subdivided to occipital and subclavian by
posterior belly of omohyoid muscle

28. • Contents of posterior triangle
−Subclavian artery
−Brachial plexus
−Spinal accessory nerve
−Posterior cervical nodes

29. Lymph node Levels of Neck
( The Memorial Sloan Kettering
Hospital –New York Classification )

30. Level I ( Submental / Submandibular)
– Below myelohyoid muscle and above the lower
margin of the hyoid bone
– Anterior to the posterior border of the submandibular
glands
– Level I a : Submental ( between the anterior bellies
of the digastric muscle)
– Level I b : Submandibular (posterolateral to the
anterior belly of digastric)

32. Level II ( Upper jugular / upper deep cervical)
• Base of skull to lower margin of hyoid bone
• Anterior to the posterior border of sternomastoid and
posterior to the posterior border of submandibular
glands
• Level II a : Anterior, lateral or medial to the internal
jugular vein
• Level II b : Posterior to the internal jugular vein with
a fat plane separating the nodes and the vein

33. Level III (Middle jugular/ middle deep
cervical nodes)
• Lower margin of hyoid to lower margin of
cricoid cartilage
• Anterior to the posterior border of SCM and
lateral to the medial margin of the CCA / ICA

34. Level IV ( Lower jugular / lower deep
cervical nodes)
• Lower margin of cricoid cartilage to level of the
clavicle
• Anterior and medial to an oblique line drawn through
the posterior edge of the sternocleidomastoid muscle
and the posterolateral edge of the anterior scalene
muscle and lateral to the medial margin of the CCA

35. • Level V (Posterior triangle nodes )
– Level V a : superior half, posterior to levels II and III
– Level V b : inferior half, posterior to level IV
• Level VI (prelaryngeal /pretracheal /Delphian node)
− From inferior margin of hyoid to manubrium
− In front of levels III and IV
• Level VII (superior mediastinal )
– Between CCAs, below top of manubrium