The document discusses the anatomy of fascial spaces in the head and neck region. It describes several layers of deep cervical fascia including the investing layer, middle layer, visceral layer, vertebral layer and alar fascia. It also outlines the boundaries and contents of various fascial spaces such as the buccal space, retropharyngeal space, submandibular space and submental space. Clinical aspects such as drainage of abscesses in these spaces are also mentioned.

1. Dr.A.GANESH BALA M.S ENT
ASSOCIATE PROFESSOR
VMMC - KARAIKAL

3. •Completely encloses the head and neck
and is generally considerd torepresent a
continuous sheeth of fatty connective
tissue (thin layer of subcutaneous
connective tissue)
extending from the head and neck into
the thorax , shoulders & maxilla.
•In the head , this layers encases the
voluntary layerof face andscalp.
•In the neck , this layer encases the
platysma ,External jugular vein,
and Sup. Lymph nodes.

4. •Lies between the dermis of the skin and
the deepcervical fascia
•Also contains a varying amount of fat -
its distinguishing
characteristic
A potential fascial space within the fatty
tissue superficial to the platysma as well
as between the latter and the deepfascia
termed as “ SpaceI of Grondinisky &
Holyoke”.

7. •the most superficial Deep Fascial Layer
•Surrounds the structures of the neck
•Lies between the superficial cervical fascia
and the muscles
•Splits into superficial and deeplayers to
enclose trapezius, SCM, submandibular gland
and fibrous capsule of parotid gland
•Covers the posterior as well as the anterior
triangle of the neck

8. • Superiorly it attaches to
Superiornuchalline ofoccipital bone(a)
Spinousprocessesofcervical vertebraeandnuchal
ligament(b)
Mastoidprocessesoftemporalbones(c)
Zygomaticarches(d)
Inferiorborderofmandible(e)
Hyoid bone(f)

9. Inferiorlyit attaches to
Manubrium(g)
Clavicles(h)
Acromion(i)

10. •Continuousposteriorlywithperiosteum covering C7
spinousprocessandligamentumnuchae–an extension
ofthe supraspinousligament thatformsa medianfibrous
septumbetween themusclesofthe twosides ofthe neck
•Justabovethe sternumthislayersplits aroundthe
anteriorandposteriorsurfacesofthemanubriumforming
theSuprasternal Space(k).Containsthe anteriorjugular
veins
•Foldstoformthe stylomandibularligament(j)

11. a- investing layer of deepcervical fascia
b- platysma muscle

12. Surrounds infrahyoid (strap) muscles: Sternohyoid,
Sternothyroid,
Omohyoid,
Thyrohyoid
Thickens to form a pulley through which the
intermediate tendon of the digastric musclepasses,
suspending the hyoid bone
MIDDLE LAYER OF DEEP CERVICAL FASCIA
A DERIVATIVE OF INVESTING FASCIA

13. Also tethers the omohyoid muscle, redirecting the
course of the muscle between the two bellies
Fused with the Investing layer of fascia that lies on
the Deep surface ofSCM
MIDDLE LAYER OF DEEP CERVICAL FASCIA
A DERIVATIVE OF INVESTING FASCIA

14. (a)- middle layer of deepcervical fascia
(b)-strap muscles
MIDDLE LAYER OF DEEP CERVICAL FASCIA
A DERIVATIVE OF INVESTING FASCIA

15. Visceral Layer of DeepCervical Fascia
•Liesdeep tothe infrahyoidmuscles, followingthem totheir
origin behindthe sternum,and splits toenclose the
thyroid,trachea,pharynx,andesophagus
•Attachedsuperiorlytothe cricoidcartilage(e), thyroid
cartilage(d), andhyoidbone(f)
•Attachedposteriorlyto the(Pre)Vertebral Fascia
VISCERAL AND PHARYNGEAL LAYER OF
DEEP CERVICAL FASCIA

16. Visceral Layer of DeepCervical Fascia
•Blends laterally with the carotid sheath and
inferiorly with the fibrous pericardium
•Blends posteriorly and superiorly with
pharyngeal fascia of the pharynx
•Continuous with Investing Fascia at lateral
borders of infrahyoid muscles
•Is refered to pretracheal anteriorly(a) and
retrovisceral(c) posteriorly.
VISCERAL AND PHARYNGEAL LAYER OF
DEEP CERVICAL FASCIA

17. Visceral Layer of DeepCervical Fascia
•Thinlayeron thepharynxitself
•OftenbrokendownintoRetropharyngeal(b),Lateral
PharyngealandBuccopharyngealcomponentsasit
posteriorlytoanteriorlyenvelops thepharynx
•Retropharyngealfasciais consideredcontinuousbelow(T2)
withthe visceral fasciaonthe
esophagus(Retrovisceral/RetroesophagealFascia)
•Separatesthemuscularwall ofthe pharynxfromcertain
potentialspaces thatlargely surroundit.
•OtherComponentsof Visceral Fasciadiscussedin detailin
Suprahyoidsection
VISCERAL AND PHARYNGEAL LAYER OF
DEEP CERVICAL FASCIA

18. Vertebral Layer of Deep Cervical Fascia
•Formsatubularsheathforthevertebral columnandthe
musclesassociatedwithit extendingfromthe baseofthe
skull toT3vertebra
•Extendslaterallyas theaxillarysheath– surroundsthe
axillaryvessels, brachialplexus,andsympathetictrunks
•Begins fromcervical spinousprocesses(a) andthe
ligamentum nuchae(b).(Similar tothe Investing Layerof
DeepCervical Fascia)
VERTEBRAL LAYER OF DEEP CERVICAL FASCIA

19. Vertebral Layer of Deep Cervical Fascia
•Initiallylies on theoutersurfaceofthe backmuscles that
extendintothe neck (nuchallayer) andis immediatelydeep
tothe trapeziusmuscle anditssurroundingsuperficiallayer
offascia.
•Coversthe floorof theposteriortriangleofthe neck.
•Isreferedtoasprevertebralanteriorly.
•Theprevertebrallayeroffasciaattachesto thetranverse
processes(c) anddivides intotwolayers/laminaeasit
passesbehind theesophagusandin frontofthe vertebral
column.
VERTEBRAL LAYER OF DEEP CERVICAL FASCIA

20. Alar fascia is the anterior subdivision of
prevertebral fascia that bridges between the
transverse processes(a).
It blends with the (retro)Visceral fascia (posterior
fascia of the esophagus) at the level of T2
vertebral body.
This seals inferiorly the (retro)Pharyngealspace.
It runs from the base of the skull to the superior
mediastinum
ALAR FASCIA – ANTERIOR SUBDIVISION OF
PREVERTEBRAL FASCIA

21. (a)- tongue
(b)- inferior concha
(c)-danger space #4
(d)- alar fascia
(e)- oropharynx
(f)- epiglottis
ALAR FASCIA – ANTERIOR SUBDIVISION OF
PREVERTEBRAL FASCIA

30.  Theanteriortriangleoftheneckis
outlinedbythe
 anteriorborderofthe
sternocleidomastoidmusclelaterally,
 theinferiorborderofthemandible
superiorly,
 andthemidlineoftheneckmedially

31.  BOUNDARIES
 Anteroinferiorly : anterior belly of digastric
 Posteroinferiorly : posterior belly of
digastric
 Superiorly or base : base of the mandible
and the line joining the angle of the
mandible and mastoid process
 CONTENT
 Submandibular gland; submandibular lymph
nodes; hypoglossal nerve [XII]; mylohyoid
nerve; facial artery and vein

32.  BOUNDARIES
 hyoidboneinferiorly,the anterior
belly ofthedigastricmuscle
laterally,andthe midline;
 CONTENTS
 Submentallymphnodes;
 Tributariesformingthe anterior
jugularvein

33.  BOUNDARIES
 Hyoid bone superiorly,
 the superior belly of the omohyoid
muscle, and the anterior border of
the sternocleidomastoid muscle
laterally,
 and the midline;
 CONTENTS
 Sternohyoid, omohyoid,
sternothyroid, and thyrohyoid
muscles; thyroid and parathyroid
glands; pharynx

34.  BOUNDARIES
 superior belly of the omohyoid
muscle anteroinferiorly,
 the stylohyoid muscle and posterior
belly of the digastric superiorly, and
 the anterior borderof the
sternocleidomastoid muscle
posteriorly.

35.  Tributaries to common facial vein
 Cervical branch of facial nerve[VII]
 Common carotid artery
 External and internal carotid arteries
 Superiorthyroid; ascending pharyngeal; lingual, facial, and occipital arteries
 Internal jugular vein
 Vagus [X], accessory [XI],and hypoglossal [XII] nerves
 Superiorand inferior roots of ansa cervicalis
 Transverse cervical nerve

36. MUSCLESSUPERIOR TO THEHYOID
 Suprahyoid muscles
 stylohyoid,
 digastric,
 mylohyoid, and
 geniohyoid;

37. MUSCLES INFERIOR TO THE HYOID
 Infrahyoid muscles
 omohyoid,
 sternohyoid,
 thyrohyoid, and
 sternothyroid.

40.  Boundaries:
 Anterior:posteriorborderof
sternocleidomastoid
 Posterior:anteriorborderof trapezius
 Inferiororbase:middleone thirdofclavicle.
 Apex:lieson thesuperiornuchalline where
thetrapeziusandsternocleidomastroid
meet.

41.  Theroofisformedbytheinvestinglayerofdeepcervical fascia.
 Thesuperficialfasciaover theposteriortrianglecontains (a)theplatysma
(b)theexternaljugularandposteriorexternaljugularveins.(c)parts ofthe
supraclavicular,greatauricular,transversecutaneousandlesseroccipital
nerves,(d)transversecervicalandsuprascapulararteriesandlymph
vesselswhichpiercethedeepfasciatoendinthesupraclavicularnodes.

42.  The floor of the posterior triangle is formed by the prevertebal layer
of the deep cervical fasciacoverting the following muscles:
 (a) splenius capitus
 (b) levator scapule
 (c) scalenusmedius andoccasionaly scalenusposterior.

43.  STERNO CLEIDO MASTOID
 TRAPEZIUS
 SPLENIUS CAPITIS
 LEVATOR SCAPULAE
 POSTERIOR SCALANE
 MIDDLE SCALANE
 ANTERIOR SCALANE
 OMOHYOID

45. CONTENTS OCCIPITAL TRIANGLE SUBCLAVIAN TRIANGLE
NERVES 1.Spinal accesory nerve
2.Fourcutaneous branchesof cervical
plexus:
a.Lesser occipital
b.Greater auricular
c. Anterior cutaneous nerveof neck
d.Supraclavicular nerve
3.Muscualar branches:
a.Two small brnaches to the levator
scapule
b.Two small branchesto the trapezius
c. Nerveto the rhomboideus
4.Upperpart of brachial plexus
1.Threetrunksof brachial plexus
2.Nerveto serratus anterior
3.Nerveto subclavius
4.Suprascapular nerve

46. CONTENTS OCCIPITALTRIANGLE SUBCLAVIANTRIANGLE
VESSELS a.Transversecervical arteryand
vein
b.Occipitalartery
a.Thirdpartofthesubclavian
arteryandsubclaviervein.
b.Suprascapulararteryandvein.
c.Commencement of transverse
cervical arteryandtermination
ofthe correspondingvein.
d.Lowerpartofthe external
jugularvein
LYMPH NODES Along theposteriorborderofthe
sternocleidamastoidmorein the
lower partthe supraclavicular
nodesanda fewatthe upper
anglethe occipitalnodes
A fewmembersofthe
superaclavicularchain

47. SPACES

51. Buccal Space Boundaries
 •Medial:Buccinator muscle
 •Lateral:Zygomaticus (lesser and greater)
and Risoriusmuscles and theirInvesting
Superficiallayerofthe Deep CervicalFascia
(SLDCF)
 •Posterior:Parotid,Mandible, Pterygoid
muscles ,Masseter & Masticator space
 •Superior:Temporal Fossa

52. Buccal Space contents
- Buccalfat pad
- Space is fierced at right angle by stenson’s duct
-Portion of the buccalpad extends posteriorly beneath
the massetor and the ramusof mandible and become
continuos with adipose tissue of the infratemporal
space.
- Parotid duct
- Accessory parotid gland

53. TheBS is filled primarily with fat, which is
called the buccal fat pad (BFP).
It consists of a central hub of fat with four
projections:
 –Superior(Superficialanddeep tothe
temporalismuscle– locatedin thetemporal
fossa)
 –Medial ( locatedin theinfratemporalfossa)
 –Anterior
 –Lateral

54.  Superiorly : Levator labii superiorris , Zygomatic
minor & Alar Nasi
 Posteriorly : Buccinator muscle
 Anteriorly : Orbicularis oris muscle
 Source of infection :
 Anterior maxillary teeth & pre-molars
 Skin of nose
 Upper lips
 (Drainage is done intraorally and carried through the
periosteum and down to the bone.)

56.  This space lies between the superficial fascia and the deep layer of the deep cervical
fascia. (Entire length of neck)
 Surrounds platysma
 Site of superficial cellulitis of neck usually secondary to supparation of lymph node.
 Clinically the signs of infection are obvious as these abscesses point and fluctuant, as
opposed to deep space neck infections.
 Treatment : I & D (Treat with incision along Langer’s lines)
and Antibiotics

57.  Entirelengthofneck.
 Anteriorborder- pharynxandesophagus(buccopharyngealfascia)
 Posteriorborder- alar layerofdeepfascia
 Superiorborder- skullbase
 Inferior border–superiormediastinum
 Combines with buccopharyngeal fascia at level of T1-T2( communicate
with the pretracheal space, )

60.  Passes downward and is continuous
with the (Retro)Visceral
(retroesophageal) space (which begins
belowthe pharynx) and opens inferiorly
into the posterior mediastinum
 Contains retropharyngeal lymph nodes
which drain the adenoids, nasal cavities,
pharynx , nasopharynx, and PNS
(posterior ethmoid sinuses ),Adjacent
muscles , Middle ear.

61. Clinical
Abscess : drained by trans oral drainage.( Horizontal incision is made over the bulging posterior
pharyngeal mucosa to establish the drainage)
If contagious space involvement suggested : External Drainage.
Horizontal incision in the neck and dissecting anterior to the anterior border of the SCM. The
greater vessels are identified and retracted laterally. RPS is then identified and entered with
blunt dissection(between the carotid sheath & and the constrictor muscle) , first laterally and
then posterior to the pharyngeal musculatare. A drain is left in position.

62. Clinical
Commonly regarded as a route through which infections of the mouth and throat reach the
mediastinum. It can break through the posterior wall of the space through the alarfascia, and
can enter Danger Space 4, between the two lamellae of the prevertebral layer of fascia
(extends from the base of the skull to the level of the diaphragm).
A sagitically oriented fibrous septum connects the anterior and the posterior pillar in the midline
and divides it into two compartments called THE SPACES OF GILLETTE. Abscess in this space is
unilateral .
Retropharyngeal edema may occur due to post radiation fluid collection and non infectious
inflammatory processes.

63. Thespacebelow C4 is normallytermed Retrovisceral.
The spacelocatedposteriortotheesophaguscan becalled
retrovisceralas well, however if youwish tobespecific,this
spacecan betermedthe Retroesophageal space.
Inferiorly,like the pretracheal,it extendsintothemediastinum
andendsatT1-T2,wherethespaceisobliteratedthrough
fusionofthe connectivetissueonthe posteriorsurfaceof
theesophagustotheprevertebralAlar layeroffascia.
A prevertebralspaceexistsbelow thislevel -Danger Space4.

64.  Clinical
 Important pathway by which infections orginating from various locations in
the head andthe upper portion of the neck reach the mediastinum.
 Theretrovisceral space may also beinfected directly from posterior
perforations of the esophagus or by infections of the deepcervical nodes
lying adjacentto it.

65. An areaofdelicatelooseconnectivetissue
Anterior: alarlayerofdeep fascia
Posterior:prevertebralfascia
Lateral:fuse tothetip oftransverseprocessof
vertebrae
Superior: baseofthe skull
Inferior:diaphragm.

66.  Infectioncancommunicate fromposteriorwall oftheoropharynxandoralcavitytothe
thoraxbytraveling fromthe RetropharyngealSpace,andpassingdownwardtothe
Retrovisceralspace(which begins belowthe pharynx).
 It canthenpierce thrutheweakalarfascia- intoDangerSpace#4
 "Dangerous" becauseaninfectioncan easilytravel tothe thoraciccageand
mediastinum,i.e., mediastinitis,empyema, sepsis
 Abscessin the mediastinumcouldgoanteriorlytothe pericardialareaandcould affectthe
manubrium,sternum,etc..

67. Potential pocket existingbetween the
"prevertebral fasciaand the
vertebral bodies.
Intervertebral discs exist between
vertebrae and are vulnerable to an
infection traveling in this space
Contents : vertebral body , prevertebral
muscles and vertebral vessels.

68. Superiorly : Skullbase
Inferiorly : Coccyx
Anteriorly : RetroPharyngealSpace & Danger Space ,
Anterolaterally : Carotid Space
Posteriorly - vertebral bodies and deep neck muscles
Lateraly – transverse processes

69.  Anymassinprevertebral spacewilldisplace theretropharyngealspace
andtheprevertebralmusclesanteriorly,iftheleisionisprimarytothe
vertebral body.
 Infectionintheneckcantrack eventopsoasmuscleduetoitsanatomical
continuity.
 Secondarymetastsisismorecommonthantheprimary
 Leukemia andmyelomacanalsobeenseen

71. Potential Cavity within the carotid sheath
which extends into the mediastinum
3 Deep Cervical fasciallayers:
Investing,
Pretracheal, and
Pre-Vertebral
Condenses to form Carotid Sheath

72. Contains the carotid artery , internal jugular vein , lymphatics , cranial nerves
IX through XII and sympathetic trunk behind.
Extends from the base of skull (where it communicates with the carotid canal or jugular foramen )to
aortic arch at the level of root of neck .
Anterolateral wall is composed of investing layer , deep to sternomastoid , and
pre-tracheal layers.
Posterior and medial wall : Pre-vertebral layer of cervical fascia.
Laterally related with parotid space , anteriorly with parapharyngeal space , and medially with
retropharyngeal space , posteriorly the vertebral bodies of the cervical spine

73. - Common and internal carotid arteries
-Internal Jugular vein
-Vagusnerve(CN X)
-Deepcervical lymph nodes
-Sympathetic fibers
-In the upperpart, the carotid sheath also contains the glossopharyngeal nerve(IX), the
accessory nerve (XI),and the hypoglossal nerve(XII), which pierce the fascia of the carotid
sheath.
-Sheath is extremely strong which prevents easy compression.
(Therefore a problem in the carotid sheath can crush the internal jugular vein and vagus nerve)

74. Clinical :Itcan beinvolved inany neck infectionbecause itis madeofthose three layers:
Investing, Pretrachealand PrevertebralFascia.
 Infections (between hyoid and root of the neck) because the sheath is closely adherent to
vessels & also arises from thrombosis of the internal jugular vein (“Picket Fence” type of fever) ,
carotid artery thrombosis , or from infection of those deep cervical lymph nodes that lie within
the sheath .
 Drug use (Heroin) usually use carotid route to obtain a fast high. A result can be abscess of the
carotid sheath presenting in a patient who is groggy with a weak pulse (bradycardia) and low
blood pressure due to the compression of the carotid sinus and irritation of the vagus nerve.

75. Vascular Infectious Benign tumors Malignant
tumour
Internal jugular
vein thrombosis
Abscess Paranganglioma Neuroblastoma
Carotid artery
thrombosis
Schwannoma Non-hodgkins
lymphoma
Cartid artery
aneurysm/
pseudo aneurysm
Meningioma from
posterior fossa via
jugular foramen
Extension of
squmous cell ca
and metastases.

77.  Is diveded into sub-lingual and sub-maxillary
space.( by the mylohyoid)
 Sub-maxillary space is further divided into
subsidiary submental and submaxillary spaces
by attachment of the superficial layer of fascia
to the anterior belly of the digastric muscle.
 A cross section reveals that the submental
space represents a median space that
separates the two submaxillary spaces.

78.  Inferior : Superfacial layer of the deep cervical fasciaextending from
the hyoidto the mandible.
 Laterally and Anteriorly : Body of mandible
 Posteriorly : Hyoid bone
 Superiorly : Mucosa of floor of the mouth

79.  Containing submental lymph nodes
 Corresponding to the triangle of the same name, lies medial to the anterior
belly of the digastric

80.  Lateral and posterior to sub-mental space
 Contains Submandibular Gland with its fascial covering, Facial Artery and
Vein, Hypoglossal Nerve,Vena hypoglossi commitantes
 These spaces consist only of an easy line of cleavagebetween the fascia and
the muscles, unless they are abnormally distended.
 Theroots of the third, second, and first molars areall below the level of the
mylohyoid.

81.  Infection of these teeth pass through the root, directly into the submaxillary
space and then to the lateral pharyngeal space.
 Patient canpresent with problems in their airway.
 Nevergivea nerveblock if there is an infection of the submandibular space.
 Infection can be passed by way of a needle tract infection to a deeperarea ofthe
body.

82. Parapharyngeal spaceistransversebythe
styloglossusandthe stylopharyngeusmuscles
andconnectsposteromediallywiththe
retropharyngealspaceandinferiorlywiththe
submandicularspace.
Laterally,itconnectswiththemasticatorspace.the
carotidsheathcoursesthroughthisspaceinto
the chest.
The spaceprovides acentralconnectionforall other
deep neck spaces.

83. Boundaries:
 baseofskullsuperiorly,
 mediallypharynxor buccopharyngealfasciaovertheconstrictors.
 Posterolaterallyparotidglandwiththedeeplayerofthedeepcervical
fascia.
 Anterolaterally,ramusofthemandiblewiththemedial pteryoidonits
innerside.
 Posteriorly,carotidsheathanditscontentsbutseparatedbythestyloid
apparatusandtheprevertebralfascia.

84.  The lateralpharyngealspacecanbedivided intoanteriorandposteriorcompartmentsbythe
styloidprocessanditsattachmanetsnamelythe 3 musclesand2 ligaments shortlyknownas the
RIOLAN’SBOUQUET.
 Theprestyloidcompartmentcalled themuscularcompartmentthe internalmaxillary
artery,inferioralveolarnerve,lingual nerve andauriculotemporalnerve,fat,lymphnodesand
muscles.
 Theretrostyloidcomparantmentsknownas theneurovascularcomparantmentcontainsthe
carotidandinternaljugular vessels,sympahticchainaswell ascranialnerversIX throughXII.
 The accessorynerveis somewhatprotectedfrompathologicalprocessin thisregion byits
positionbehindthesternocleidomastoidmuscle.

85. 1.infectionscansrisefromthetonsils,pharynx,dentition,salivaryglands,nasalinfections,petrousportionofthe
temporalboneorbezoldabscess.
Infectionsoftheprestyloidcomparantmentpresent withpain,fever,externalswelling below theangle of
jaw,prolapsedoftonsils,tonsillarfossaandtrismus.
Omnioussigns ofretrosyloidcomparantmentinvolvement include Hornersyndrome.
CranialnerveIX andXII palasis,bulgeofpharynxbehind theposteriorpillarandcomplicationsinclude septic
jugularthrombophlebitsandcarotidarteryerosionor thrombosis
Hematogenousdissemelation canalsooccur withthe majorvessel involvemet.
Drainageis byusing a horizontalincision or anincision alongthe anteriorborderofthe sternomastoid.

86. 2.Theparapharyngeal spaceabsess reaches the mediastinum through the
“LINCONS HIGHWAY”(CAROTID SHEATH).
3. EAGELS SYNDROME: it is seenin cases of congenital elongated styloid process oracquired
elongation dueto ossification of the stylohyoid ligament. The elongated styloid process
impinges onthe glossopharyngeal nerveand produces stylalgia.
4.Asuperficial parotid swelling like plemorphic adenoma can pass through the
stylomandibular tunnel and may present in the parappharyngeal space forming a Dumb
Bell tumour.
5. Masses in the surrounding spaces displace the pharyngeal space fat. Assessing the centre od
a deepfascial mass relative to the parapharyngeal space and observing the direction in
which this mass displaces the fat,the site of the lesion can be localized radiologically.

87. The palatinetonsils arepairedlymphoidorgans
foundbetween the palatoglossaland
palatopharyngealfoldsoftheoropharynx.
Theyaresurroundedbya thincapsule thatseperates
the tonsilsfromthesuperior andmiddle
constrictormuscles.
The anteriorandposteriorpliiarsformthefrontand
backlimits ofthe peritonsillarspace.
Superiorly,thispotentialspaceis relatedtothe torus
tubarius,whileinferiorlyiit is boundedbythe
pyriformsinus.
Looseconnectivetissuesis themajorcontent.

89. Applied clinical significance
 1.Peritonsillar abscess/quinsy is produced usually following tonsillitis and presents with
odynophagia,hot potato voice,trisums,ipsilateral otalgia. Theinflammation and
suppurative process of the space may extend to involve the soft palate , the lateral wall of
the pharynx and occasionally, the base of the tongue.
 2.The tonsillar fossa has a rich network of lymphatic vessels leading to the paraphyngeal
space and the upper cervicallymph nodes.which explains the pattern of adenopathy
Observerdclinically. Ipsilateral upper cervical lymphadenopathy is the result of the spread
ofthe infection to the regional lympahtics. occasionally the severity ofthe suppurative
process may lead to the cervical abscess,especially in veryfulminant orrapidly progressive
cases.

90.  3. Earlyabsesses generally extend superior and anterior. Later
posterior extension allows it to decompress into the parapharyngeal
space. Hence allperitonsillar abscesses are potential parapharyngeal
or retropharyngeal abscesses.
 4. The treatment includes Hydration,Analgesics,Antibiotics,Surgical
intervation including I&D with interval tonsillectomy.

92.  Superior:skullbase
 Inferior :inferiorsurfaceofmandible.
 Superomedially:thefasciaattachestotheskullbasejustmedial to
foramenovale
 Superolaterally:zygomaticarch
 Laterally: medialpterygoidfascia
 Medially:massetermuscle
 Anterolateraaly:parapharyngealspace

93.  CONTENTS :
 Pterygoid andMassetor muscles
 Insertion of Temporalis tendon
 Inferior Alveolar nerve& vessels

94. Clinical
 Infections of the zygomatic or temporal bones may pass to the masticator space, and so
may abscesses from the lower molar teeth
 Abscesses within this space may apparently point at the anterior aspect of the masseter
muscle, either into the cheek or the mouth, or they may point posteriorly below the
parotid gland.
 Drainage : Intraoral approach
 External approach : Horizontal incision along the angle of mandible.

95. Congenital / Devolopement Inflammatory/ Infectious Neoplastic
Haemangioma Odontogenic
infections,abscess,
cellulitis
Osteosarcoma
Venolymphatic
malformation
Myositis Rhabdomyosarcoma
Masseteric hypertrophy Non hodgkin’s lymphoma
Deep extension of mucosal
squamous cell carcinoma
Metastic disease
Bening tumors of the
muscle and bone
Nerve sheath tumour

96.  Encloses the parotid gland and
its associated lymph nodes and
the facialnerve and great vessels
traversing it.
 Attached to its surrounding
fascialikethe submandibular
gland

97.  Anteriorly : Masticator space
 Anterolaterally : Parapharyngeal Space
 Posteromedially : Carotid Space
 Laterally : Sub-cutaneous fat
 Postero-superiorly : Temporal bone

98.  Contents :
 Parotid gland
 Facial nerve
 Intraparotid lymphnodes
 Parotid duct exits anteriorly
 External carotid artery
 Posterior facial vein

99.  Clinical: Though the deep surface of the parotid gland is strong,
infections (usuallyof the glands or the nodes) may readilypass
deeply and therefore into the important lateralpharyngeal space
lying deep to the parotid gland.
 When orally palpating and examining the area, it is important to note
that the deep fasciaaround the parotid gland is weaker medially
than laterally. Therefore an infection in this space can evidence itself
asa bulge that sticksout medially into the oral cavity.

100. Deveopement Infectious Benign tumours Malignancy
Pleomorphic adenoma Mucoepidermoid
carcinoma
Haemangioma Parotitis Warthin’s tumour Adenocystic ca
Venolymphatic
malformation
Parotid abscess Lipoma Acinic cell ca
1st branchial cleft cyst Reactive
lypfadenopathy
Facial nerve
schwannoma
Carcinoma ex
pleomorphic adenoma
Lymphoepithelial cysts
or lesions
Oncocytoma Salivary ductal ca
Squamous cell ca
Nodal and extra nodal
hodgkins lymphoma
and metastases

101.  Defined by both the superficial and deep layer of the deep cervical
fascia.
 Superior : Skullbase
 Inferior : Clavicle
 Anterior : Carotid space
 Medial : Peri-vertebral Space
 Lateral : Sternomastoid & Sub-cutaneous fat.

102.  Contents :
 Fat
 Cranial nerveXI
 Lymph nodes
 Trunks of branchial plexus

104.  Bounded anteriorly by pretracheal fasciaand posteriorly by
prevertebral fascia
 Contents :
 Thyroid gland
 Parathyroid gland
 Larynx
 Trachea
 Hypopharynx
 Osephagus

105. Surroundingthetracheaandlying againstthe anteriorwall ofthe
esophagus
Anteriorly- bytheInvesting Cervical Fascia
Posteriorly- byVisceral Cervical Fascia
Above- bytheattachmentsof theInfra-hyoidMuscles andtheir
FasciaTo TheThyroidCartilage andto theHyoid Bone
Below - continuesintotheanteriorportionofthe Superior
mediastinum
Inferiorly-bytheSternumandScaleneFascia

106. Extends to approximately the arch of the
aorta to about the level of the T4
vertebrae where the posterior surface
of the sternum and the fibrous
pericardium are united by denser
connective tissue
Contents: Infrahyoid Strap muscles

107.  Clinical:
Can beinfecteddirectlybyanteriorperforationsorruptureoftheesophagusor
indirectlybyspreadfromtheretrovisceralportion,aroundthesidesofthe
esophagusandthyroidglandbetweenthelevelsoftheinferiorthyroidartery
andtheobliquelineofthethyroidcartilage.
Bothpretrachealandretrovisceralspacesdescendintothesuperiormediastinum.

108.  Formed superior to the manubrium
wherethe Investing Fasciadivided into
two layers attachedto the anterior and
posterior surfaces of the manubrium.
 Encloses the sternal heads of theSCM’s,
the inferior endsof the anterior jugular
veins, the jugularvenous arch, fat anda
few lymphnodes

109.  Clinical:
 Above this space lies the JACKSON’S TRIANGLE (used for tracheostomy) formed
superiorly by the cricoid cartilage and on eitherside by the anterior borderof the
sternemastoids.
 TraumatothisSPACEcancausea bleederandsubsequentlya large
bulgingabovethemanubriumandevenmightdistenddownposteriorto
themanubriumintothesuperiormediastinum.

110.  Near the root of the neck the investing layer splits into 2 layers, the
superficial layer attachesto the upper border and the deep layer
attachesto the lower border of the back of the claviclein the
region of the lower part of the post. triangle thereby creating the
omohyoid space

112.  LYMPH NODE LEVELS
 SUBMENTAL& SUBMANDIBULAR
 UPPER JUGULAR GROUP
 MIDDLE JUGULARGROUP
 LOWERJUGULAR GROUP
 POSTERIORTRIANGLEGROUP
 ANTERIOR(OR)CENTRALGROUP

114.  IA – Sub-mental nodes
 Drains : anterior floor of mouth , lower lip & ventral tongue.
 IB – Sub-mandibular nodes
 Drains : Other subsites in oral cavity

115.  II A – Lies antero-inferior to the spinalaccessory nerve
 II B – Lies postero-superior to the spinal accessory nerve
(also known assub-muscular recess)
 Drains : oropharynx , larynx , hypopharynx & parotid.

116.  LEVEL III is not further sub-divided.
 Drains : pharynx & larynx

117.  LEVEL IV is not further sub-divided.
 Drains : Hypopharynx & larynx

118.  VA – Superior To The Inferior Belly Of Omohyoid
 Drains : Nasopharynx( contain the chain along the accessory nerve)
 VB– Inferior To The Inferior BellyOf Omohyoid
 Drains : Thyroid gland ( more related to thryocervical trunk)

119.  Includes Paratracheal ,Perithyroidal & Delphian nodes