Deep neck spaces are anatomical compartments in the neck, defined by the deep cervical fascia, that play a crucial role in understanding various pathologies, particularly infections.

Deep Neck Spaces
Dr. Jennifer Rager
Geisinger Medical Center

Outline
 Anatomy of the Cervical Fascia
 Anatomy of the Deep Neck Spaces
 Deep Neck Space Infections

Cervical Fascia
 Superficial Layer
= subcutaneous tissue
 Deep Layer
Superficial
= investing layer
Middle
= pre/peritracheal
Deep
= pre/perivertebral
Carotid Sheath

Superficial Cervical Fascia
 lies between the dermis and
the deep cervical fascia
 superiorly it continues as
the superficial
musculoaponeurotic system
(SMAS) of the face

Superficial Cervical Fascia
 Contains:
 Neurovascular supply
to skin
 Superficial veins
 (e.g. EJ vein)
 Superficial lymph
nodes
 Fat
 Platysma muscle

Deep Cervical Fascia
 Superficial Layer
 Attachments:
 Superior – external occipital
protuberance and superior
nuchal line of the skull.
 Anteriorly – hyoid bone.
 Inferiorly – spine and
acromion of the scapula, the
clavicle, and the manubrium
of the sternum.
 Posterior – along the nuchal
ligament of the vertebral
column

 Contains:
 Sternocleidomastoid
 Trapezius
 Submandibular gland
 Parotid gland

 Middle Layer
 Attachments:
 Superiorly - skull base.
 Anteriorly - hyoid bone,
thyroid cartilage,
manubrium.
 Inferiorly - fibrous
pericardium, adventitia of
the aortic arch.

 Middle Layer
 Muscular Part
 Infrahyoid Strap
Muscles
 Visceral Part
 Pharynx, Larynx,
Esophagus, Trachea,
Thyroid
 posterior aspect is
formed along with the
buccopharyngeal fascia
(fascia of the pharynx)

 Deep Layer
 Attachments:
 Superiorly - cranial base
 Inferiorly - lower limit of the longus
colli muscle at the level of the body
of T3 vertebral column (where it
blends with the endothoracic fascia
peripherally and to the anterior
longitudinal ligament centrally)
 Laterally - becomes the axillary
sheath, surrounding the axillary
artery, the axillary vein and brachial
plexus

 Deep Layer
 Alar Layer
 Posterior to visceral
layer of middle fascia
 Anterior to
prevertebral layer
 Prevertebral Layer
 Vertebral bodies
 Deep muscles of the
neck

 Carotid Sheath
 formed by contributions from
all three layers of deep fascia

runs between the base of the
skull to the thoracic
mediastinum
 Contains:
 carotid artery
 internal jugular vein
 vagus nerve
 “Lincoln’s Highway”

Deep Neck Spaces
 Spaces created by fascial planes
 May be real or potential
 May expand when pus separates
fascia
 Communicate with each other,
forming avenues by which infections
may spread
 Described in relation to the hyoid:
 Entire length of the neck
 Suprahyoid
 Infrahyoid

Entire Length of the Neck
Deep Neck Spaces
 Retropharyngeal Space
 Danger Space
 Pre/perivertebral Space
 Carotid Space (visceral/vascular)

Deep Neck Spaces
 Retropharyngeal
Space
 Extends from skull
base to ~T4
 Anterior - middle
layer of deep cervical
fascia (pharynx and
esophagus)
 Posterior - alar layer
of deep fascia

Deep Neck Spaces
 Danger Space (4)
 potential for rapid spread of infection
to the posterior mediastinum through
its loose areolar tissue
 Extends from skull base to diaphragm
 a potential space between alar and
prevertebral layers of the deep layer
of deep cervical fascia
 posterior to the retropharyngeal space
(3) and anterior to the prevertebral
space (5)

Deep Neck Spaces
 Pre/perivertebral Space (5)
 enclosed entirely by the deep layer of
deep cervical fascia
 Extends along entire length of vertebral
column skull base to the coccyx
 Anterior - prevertebral fascia
 Posterior - vertebral bodies
 2 main divisions divided by lateral
fascial attachments to the vertebral
transverse processes
 prevertebral and paraspinal spaces
 Lies directly behind danger space

Deep Neck Spaces
 Carotid Space
 area enclosed by the
carotid sheath; a structure
formed from all 3 layers
of deep fascia
 “Lincoln’s Highway”
 can become
secondarily involved
with any other deep
neck space infection
by direct spread

Suprahyoid Deep Neck Spaces
 Sublingual Space
 Submandibular Space
 Peritonsillar Space
 Parapharyngeal Space
 Pharyngeal Mucosa Space
 Masticator Space
 Parotid Space

 Sublingual Space
 potential space that lies entirely within the
oral cavity (no fascial margins)

paired space, 2 sides communicate anteriorly
through an isthmus under frenulum of the
tongue

Anterior - mandible
 Inferolateral - mylohyoid

Medial - genioglossus and geniohyoid
 at the posterior margin of the mylohyoid the
sublingual space communicates directly with
parapharyngeal space and submandibular
space

 enclosed by superficial layer of
deep cervical fascia
 extends from the hyoid bone to
floor of the mouth (mylohyoid
muscle)
 Anterolateral - mandible and
 Inferior - superficial layer of deep
cervical fascia
 communicates freely with the
sublingual space and the
parapharyngeal space

 between palatine tonsil and
superior constrictor muscle
 Anterior – anterior tonsil
pillars
 Posterior – posterior tonsil
pillars
 Inferior - posterior tongue
 Medially - capsule of the
palatine tonsil
 Lateral - superior pharyngeal
constrictor

 petrous apex at the base of
skull to greater cornu of hyoid
 Superior - skull base
 Inferior - hyoid
 Anterior - ptyergomandibular
raphe
 Posterior - prevertebral fascia
 Medial - buccopharyngeal
fascia
 Lateral - superficial layer of
deep fascia

2 Compartments
 Prestyloid
 Medial—tonsillar fossa
 Lateral—medial pterygoid
 Contains fat, connective
tissue, nodes
 Poststyloid
 Carotid sheath
 Cranial nerves IX, X, XII

 Pharyngeal Mucosal Space
 mucosal surface of the
nasopharynx, oropharynx, and
hypopharynx
 skull base to the cricoid
cartilage
 contains mucosa, lymphoid
tissue of Waldeyer’s ring,
adenoids, tonsils, minor salivary
glands, the torus tubarius,
pharyngobasilar fascia, and the
cartilage of the Eustachian tubes


from the high parietal
calvarium to mandibular angle

divided into medial and lateral
compartments by the ramus of
mandible
 can serve as a conduit for
perineural intracranial spread
of malignancy, along the
trigeminal nerve, through the
foramen ovale into Meckel’s
cave

Suprahyoid Neck Spaces
 Parotid Space

formed by superficial layer of
deep cervical fascia as it splits to
surround the parotid gland.
 extends from external auditory
canal to the angle of the mandible
 posterior to the masticator space
and lateral to the carotid space and
parapharyngeal space
 Direct communication to
parapharyngeal space (no fascia
superiomedially)

Infrahyoid Deep Neck Spaces
 Visceral Space
 cylindrical, central, enclosed by the
middle layer of deep cervical fascia
 the only space found entirely in the
infrahyoid neck
 extends from the hyoid bone down
into the mediastinum
 comprises the viscera of the larynx,
trachea, hypopharynx, esophagus,
thyroid, parathyroid glands, and
recurrent laryngeal nerves

Deep Neck Space Infections
 Presentation/Origin of Infection
 Microbiology
 Imaging
 Treatment
 Complications
 Special Consideration

Presentation/Origin
 Retropharyngeal Abscess
 50% occur in patients 6-12 months of age
 96% occur before 6 years of age
 Children--fever, irritability, lymphadenopathy,
torticollis, poor oral intake, sore throat, drooling
 Adults--pain, dysphagia, anorexia, snoring, nasal
obstruction, nasal regurgitation
 Dyspnea and respiratory distress
 Lateral posterior oropharyngeal wall bulge

Presentation/Origin
 Pediatrics
 Cause—suppurative
process in lymph nodes
 Nose, adenoids,
nasopharynx, sinuses
 Adults
 Cause—trauma,
instrumentation,
extension from
adjoining deep neck
space

Presentation/Origin
 Danger Space
 Presentation and exam nearly identical to
retropharyngeal space infection
 Cause—extension from retropharyngeal,
prevertebral or parapharyngeal space

Presentation/Origin
 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

Presentation/Origin
 Pain, drooling, dysphagia, neck
stiffness
 Anterior neck swelling, floor of
mouth edema
 Cause—70-85% have odontogenic
origin
 First molar and anterior
 Second and third molars
 Sialadenitis, lymphadenitis,
lacerations of the floor of mouth,
mandible fractures

Presentation/Origin
 Ludwig’s angina
 1. Cellulitis, not always abscess
 2. Limited to SM space
 3. Foul serosanguinous fluid, no
frank purulence
 4. Fascia, muscle, connective
tissue involvement, sparing
glands
 5. Direct spread rather than
lymphatic spread
 Tender, firm anterior neck
edema without fluctuance
 “Hot potato” voice, drooling
 Tachypnea, dyspnea, stridor

Presentation/Origin
 Fever, chills, malaise
 Pain, dysphagia, trismus
 Medial bulge of lateral
pharyngeal wall
 Cause—infection of pharynx,
tonsil, adenoids, dentition,
parotid, mastoid, suppurative
lymphadenitis, extension from
other deep neck spaces

Presentation/Origin
 Fever, malaise
 Dysphagia, odynophagia
 “Hot-potato” voice,
trismus, bulging of superior
tonsil pole and soft palate,
deviation of uvula
 Cause—extension from
tonsillitis

Presentation/Origin
 Pain, trismus
 Posterior FOM
edema
 Swelling along
ramus of
mandible
 Cause—
odontogenic,
from third molars
 Parotid Space
 Pain, trismus
 Medial bulge
of posterior
lateral
pharyngeal
wall
 Cause—
parotitis,
sialolithiasis,
Sjogren’s
syndrome

Presentation/Origin
 Visceral Space
 Hoarseness, dyspnea, dysphagia, odynophagia
 Erythema, edema of hypopharynx, may extend to
include glottis and supraglottis
 Anterior neck edema, pain, erythema, crepitus
 Cause—foreign body, instrumentation, extension
of infection in thyroid

Microbiology
 Preantibiotic era—S.aureus
 Currently—aerobic Strep species and non-strep
anaerobes
 Gram-negatives uncommon
 Almost always polymicrobial
 Remember resistance

Imaging
 Lateral neck plain film
 Screening exam—mainly
for retropharyngeal and
pretracheal spaces
 Normal: 7mm at C-2,
14mm at C-6 for kids,
22mm at C-6 for adults
 Technique dependent
 Extension
 Inspiration

Imaging
 High-resolution Ultrasound
 Advantages
 Avoids radiation
 Portable
 Disadvantages
 Not widely accepted
 Operator dependent
 Inferior anatomic detail
 Uses
 Follow infection during therapy
 Image guided aspiration

Imaging
 Contrast enhanced CT
 Modality of choice
 Advantages
 Quick, easy
 Widely available
 Familiarity
 Superior anatomic detail
 Differentiate abscess and
cellulitis
 Disadvantages
 Ionizing radiation
 Allergenic contrast agent
 Soft tissue detail
 Artifact

Imaging
 MRI
 Advantages
 No radiation
 Safer contrast agent
 Better soft tissue detail
 Imaging in multiple planes
 No artifact by dental fillings
 Disadvantages
 Increased cost
 Increased exam time
 Dependent on patient
cooperation
 Availability

Treatment
 Airway protection!
 Antibiotic therapy
 Surgical drainage

Treatment
 Airway protection
 Observation
 Intubation
 Direct laryngoscopy: possible risk of rupture and
aspiration
 Flexible fiberoptic
 Tracheostomy
 Ideally = planned, awake, local anesthesia
 Abscess may overlie trachea
 Distorted anatomy and tissue planes

Treatment
 LUDWIG’S ANGINA = PERILOUS AIRWAY
 Parhiscar and Har-El
 Review of 210 patients with
deep neck abscess
 Overall, 20.5% required
tracheostomy
 Ludwig’s angina, 75%
required tracheostomy
 Attempted intubation in 20 patients
 Failed in 11 patients, necessitating
“slash” tracheostomy

Treatment
 Antibiotic Therapy
 Improvement in 24-48 hours
 Cellulitis vs Abscess
 Polymicrobial infections
 Aerobic Strep, anaerobes
 Ampicillin/sulbactam with metronidazole
 Beta-Lactam resistance in 17-47% of isolates
 Alternatives
 Third generation Cephalosporins
 Clindamycin
 Culture and sensitivity

Treatment
Treatment
 Surgical Drainage
Surgical Drainage

Transoral
Transoral
 Preoperative CT—where are the great vessels?
Preoperative CT—where are the great vessels?
 Cruciate mucosal incision, blunt spreading through
Cruciate mucosal incision, blunt spreading through
superior pharyngeal constrictor
superior pharyngeal constrictor

External
External
 EXPOSURE, EXPOSURE, EXPOSURE
EXPOSURE, EXPOSURE, EXPOSURE
 Anterior vs. Posterior
Anterior vs. Posterior
 Submandibular incision
Submandibular incision
 Submental incision
Submental incision
 T-incision
T-incision

Treatment
 Image-guided Aspiration
 Patient selection
 Smaller abscesses, limited extension, uniloculated
 Poe, et al: CT guided aspiration
 Early specimen collection, reduced expense, avoidance
of neck scar
 Yeow, et al: Ultrasound guided aspiration
 8/10 patients successfully treated with needle aspiration
 5/5 patients successful treated with pigtail catheter
insertion

Complications
 Airway obstruction
 Endotracheal intubation
 Tracheostomy
 Ruptured abscess
 Pneumonia
 Lung Abscess

Complications
 Internal Jugular Vein Thrombosis
 Lemierre’s syndrome
 F/C, prostration, swelling and pain along SCM
 Bacteremia, septic embolization, dural sinus
thrombosis
 IV drug abusers
 Treatment
 IV antibiotic therapy
 Anticoagulation?
 Ligation and excision

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
 Treatment
 Proximal and distal control
 Ligation
 Patching or grafting?

Complications
 Mediastinitis
 Mortality of 40%
 Increasing dyspnea, chest pain
 CXR = widened mediastinum
 Treatment
 EARLY RECOGNITION AND INTERVENTION
 Aggressive IV antibiotic therapy
 Surgical drainage
 Transcervical approach
 Chest tube vs. thoracotomy

Special Consideration
 Recurrent Deep Neck Space Infection
 THINK CONGENITAL ABNORMALITY
 Imaging should help make the diagnosis
 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

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Deep neck spaces are anatomical compartments in the neck, defined by the deep cervical fascia, that play a crucial role in understanding various pathologies, particularly infections.

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