DR BHUSHAN LAKHKAR

NECK SPACES
By knowing location and contents of each By knowing location and contents of each
space and pathology can be identified. space and pathology can be identified.
Like real estate, Like real estate,
Location s Everything Location s Everything
SuperIicial cervical Iascia
Cervical Fascia Cervical Fascia
ascial planes divide the neck in various ascial planes divide the neck in various
anatomic compartments. anatomic compartments.
W SuperIicial layer
W iddle layer
uscular division
Visceral division
W eep layer
Prevertebral division
Alar division
eep cervical Iascia
$uperficial Layer of cervical fascia $uperficial Layer of cervical fascia
Deep to skin and superficial to the superficial Deep to skin and superficial to the superficial
layer of deep cervical fascia. layer of deep cervical fascia.
Covers head, face, and neck. Covers head, face, and neck.
atty loose CT. atty loose CT.
Platysma. Platysma.
Muscles of acial Expression. Muscles of acial Expression.
Superiorly, it encircles Superiorly, it encircles
submandibular gland submandibular gland, muscles o , muscles o
mastication and mastication and parotid gland parotid gland. .
eep cervical Iascia
t completely encircles the neck, t completely encircles the neck,
incorporating sternocleidomastoid and incorporating sternocleidomastoid and
trapezius muscles. trapezius muscles.
t attaches posteriorly to the ertebral t attaches posteriorly to the ertebral
spines and nuchal ligament. spines and nuchal ligament.
SuperIical layer
Lncircles viscera of neck, such as larynx Lncircles viscera of neck, such as larynx
and and hypopharynx hypopharynx. .
Posteriorly Posteriorly, it is close to , it is close to alar alar fascia, virtual fascia, virtual
space between them is known as space between them is known as
retropharyngeal space retropharyngeal space. .
Above hyoid bone, it opens toward the Above hyoid bone, it opens toward the
mouth and nose, at mouth and nose, at suprahyoid suprahyoid level middle level middle
layer is known as layer is known as buccopharyngeal buccopharyngeal fascia fascia. .
Middle layer of Deep Middle layer of Deep
Cervical fascia Cervical fascia
riginates from cervical riginates from cervical spinous spinous processes processes
and and nuchal nuchal ligament. ligament.
Lxtends to either side, covering deep Lxtends to either side, covering deep
muscles of neck and attaches to transverse muscles of neck and attaches to transverse
processes . processes .
It divides: dorsal layer is known as It divides: dorsal layer is known as
prevertebral prevertebral fascia, covers fascia, covers prevertebral prevertebral
muscles,. muscles,.
ventral layer is known as ventral layer is known as alar alar fascia, it is fascia, it is
separated from separated from prevertebral prevertebral fascia by some fascia by some
loose connective tissue referred to as loose connective tissue referred to as
danger space danger space. .
Deep layer of Deep Cervical fascia Deep layer of Deep Cervical fascia
Carotid $heath ormed by all three Carotid $heath ormed by all three
layers of deep fascia Contains carotid layers of deep fascia Contains carotid
artery, internal jugular vein, and vagus artery, internal jugular vein, and vagus
nerve nerve
Cervical ascia Cervical ascia
#ed .. sup lay oI deep cer Iascia
Green .middle layer
Blue .deep layer
!arapharyngeal Space. !arapharyngeal Space.
!haryngeal Mucosal Space. !haryngeal Mucosal Space.
Masticator Space. Masticator Space.
!arotid Space. !arotid Space.
Carotid Space. Carotid Space.
Retropharyngeal Space Retropharyngeal Space
!eriertebral Space. !eriertebral Space.
$uprahyoid Neck $paces $uprahyoid Neck $paces
1 ParapharyngeaI s.
2 Masticator space.
3 Carotid space.
4 Parotid space.
5 MucosaI space.
6 PerivertebraI space.
7 RetropharyngeaI space.
ivided into two spaces:
Prevertebral Space
Paravertebral Space
Perivertebral Space
Separated by deep layer oI deep cervical
Iascia attaching to transverse processes oI
cervical vertebrae.
nterior long ligament nterior long ligament
Vertebral body,Discs Vertebral body,Discs
Muscles.. Longus coli, Muscles.. Longus coli,
Longus capatis Longus capatis
Phrenic nerve Phrenic nerve at at
Wntire length oI neck
WAnterior border - prevertebral Iascia
WPosterior border - vertebral bodies
Prevertebral $pace: Prevertebral $pace:
Paravertebral $pace: Paravertebral $pace:
Paraspinal muscles Paraspinal muscles
$calenes $calenes
Levator scapulae Levator scapulae
$plenius capitus $plenius capitus
$plenius cervicus $plenius cervicus
Brachial plexus roots Brachial plexus roots
Vertebral artery & vein Vertebral artery & vein
at at
Metastatic breast carcinoma contained in paravertebral space by deep
layer of deep cerical fascia.
Paravertebral $pace Paravertebral $pace
nhancement o ith cerical nhancement o ith cerical
ertebra, enhancing sot tissue ertebra, enhancing sot tissue
thickening in the preertebral thickening in the preertebral
space , and epidural space space , and epidural space
Non Non--lodgkin lymphoma. lodgkin lymphoma.
rosie changes seen in cerical ertebral end plates.. rosie changes seen in cerical ertebral end plates..
anger Space anger Space
mportant for spread of cranial and cervical mportant for spread of cranial and cervical
disease into mediastinum. disease into mediastinum.
Cannot be distinguished by imaging from Cannot be distinguished by imaging from
retropharyngeal space. retropharyngeal space.
Wntire length oI neck
WAnterior border - alar layer oI deep Iascia
WPosterior border - prevertebral layer
Wtends Irom skull base to diaphragm
Carotid $pace Carotid $pace
Long space Long space -- -- skull base to arch of aorta. skull base to arch of aorta.
Can become secondarily involved with any other Can become secondarily involved with any other
deep neck space infection deep neck space infection
%his is another major highway through which %his is another major highway through which
tumors can race ertically up and down rom the tumors can race ertically up and down rom the
skull base down to the aortic arch. skull base down to the aortic arch.
Contents: Contents: nternal and common nternal and common
carotids, internal jugular veins, lymph carotids, internal jugular veins, lymph
nodes,, cranial nerves (X, X, X, & X), nodes,, cranial nerves (X, X, X, & X),
LNs and fat. LNs and fat.
A nonhomogeneous mass in carotid space, displacing internal A nonhomogeneous mass in carotid space, displacing internal
carotid artery anteromedially and internal jugular vein (arrow) carotid artery anteromedially and internal jugular vein (arrow)
posterolaterally. posterolaterally.
Vagal schwannoma. Vagal schwannoma.
Parapharyngeal $pace Parapharyngeal $pace
Prestyloid (ventral) Prestyloid (ventral)
Lateral to pharynx Lateral to pharynx
Deep to masticator Deep to masticator
space and ramus of space and ramus of
mandible. mandible.
Contains fat and CT. Contains fat and CT.
Parotid protrudes into it. Parotid protrudes into it.
Retrostyloid (dorsal) Retrostyloid (dorsal)
Carotid sheath. Carotid sheath.
Parapharyngeal Abscess Parapharyngeal Abscess
Pharyngeal Mucosal $pace Pharyngeal Mucosal $pace
Contents: Contents:
Mucosal surace, also lymphoid tissues, tonsils, muscles Mucosal surace, also lymphoid tissues, tonsils, muscles
o pharynx and palate. o pharynx and palate.
Most common mass: Most common mass:
Squamous cell carcinoma Squamous cell carcinoma ,SCCA, ,SCCA,, lymphoma, less , lymphoma, less
common minor saliary gland tumors. common minor saliary gland tumors.
Collection in the left tonsillar pillar.
The ipsilateral parapharyngeal fat
is obscured. Masticator space fat
planes are obliterated as well, with
swelling of the ipsilateral medial
pterygoid muscle.
$ubmandibular $pace $ubmandibular $pace
Divided by mylohyoid muscle Divided by mylohyoid muscle
into: into:
1.$ublingual $pace 1.$ublingual $pace
(more cranial) (more cranial)
2.$ubmylohyoid/$ubmaxillary 2.$ubmylohyoid/$ubmaxillary
(more caudal) (more caudal)
$ubmandibular $pace $ubmandibular $pace
Contains the submandibular gland, Contains the submandibular gland,
submandibular nodes, portions o submandibular nodes, portions o
acial ein and artery and inerior acial ein and artery and inerior
loop o cranial nere . loop o cranial nere .
!leomorphic adenoma. !leomorphic adenoma.
Masticator $pace Masticator $pace
1 ParapharyngeaI s.
2 Masticator space.
3 Carotid space.
4 Parotid space.
Contents: Contents:
Mandible, Mandible,
Muscles .. temporalis, masseter, medial, Muscles .. temporalis, masseter, medial,
lateral pterygoids, lateral pterygoids,
Branch of trigeminal nerve (V3), Branch of trigeminal nerve (V3),
Branches of external carotid and jugular Branches of external carotid and jugular
venous system. venous system.
Most common mass: Most common mass:
Dental $tuff/Mandibular Disease (Odontogenic bscess/Osteo) Dental $tuff/Mandibular Disease (Odontogenic bscess/Osteo)
Muscle (Tumor/nflammatory ) Muscle (Tumor/nflammatory )
Nerve (schwannoma/N) Nerve (schwannoma/N)
nvasive carcinomas from oral cavity nvasive carcinomas from oral cavity
Abscess ormation in let Abscess ormation in let
masticator space, originating masticator space, originating
rom a dental abscess. rom a dental abscess.
Parotid $pace Parotid $pace
Contents: Contents: !arotid gland, acial nere, lymph !arotid gland, acial nere, lymph
nodes, arteries and eins. nodes, arteries and eins.
Common mass: Common mass: !arotid tumor ,metastatic !arotid tumor ,metastatic
lymph nodes. lymph nodes.
ateral.. Parapharyngeal space ,
Posterolateral to asticator space,.
edial.. carotid space, separated by post belly oI digastric
tends Irom level oI et auditory canal to angle oI
mandible
Masses in the parotid glands. Bilateral Warthin's tumors.
Parotid $pace Parotid $pace 12W 12W
!leomorphic adenoma !leomorphic adenoma
#etropharyngeal $pace #etropharyngeal $pace
'irtual space behind the pharynx, 'irtual space behind the pharynx,
Limited anteriorly by middle layer o deep cerical Limited anteriorly by middle layer o deep cerical
ascia, and posteriorly by alar ascia o deep layer ascia, and posteriorly by alar ascia o deep layer
o deep cerical ascia o deep cerical ascia
xtends rom the skull base to the leel o third to xtends rom the skull base to the leel o third to
ourth thoracic ertebra, where the aboe ourth thoracic ertebra, where the aboe--
mentioned layers use. mentioned layers use.
Retropharyngeal space contains retropharyngeal lymph nodes and Retropharyngeal space contains retropharyngeal lymph nodes and
at. at.
Retropharyngeal abscess Retropharyngeal abscess
Infrahyoid Neck $paces Infrahyoid Neck $paces
%hese spaces continue largely unchanged rom %hese spaces continue largely unchanged rom
aboe the hyoid: aboe the hyoid:
Carotid Space. Carotid Space.
Retropharyngeal Space ,no nodes below hyoid,. Retropharyngeal Space ,no nodes below hyoid,.
Danger Space. Danger Space.
!eriertebral Space. !eriertebral Space.
%wo new major spaces: %wo new major spaces:
'isceral Space. 'isceral Space.
!osterior Cerical Space !osterior Cerical Space
ascia of the nfrahyoid Neck ascia of the nfrahyoid Neck
$uperficial layer $uperficial layer
Encircles the infrahyoid neck Encircles the infrahyoid neck
Middle layer (visceral) Middle layer (visceral)
Deep layer (perivertebral) Deep layer (perivertebral)
Encircles the perivertebral Encircles the perivertebral
space space
Visceral Compartment Visceral Compartment
Contains pharynx, esophagus, trachea, thyroid, Contains pharynx, esophagus, trachea, thyroid,
parathyroids, larynx, parathyroids, larynx,
Two divisions separated by fascia Two divisions separated by fascia
nterior, the Pretracheal space, which extends to nterior, the Pretracheal space, which extends to
superior mediastinum. superior mediastinum.
Posterior, the Retrovisceral space, which extends to Posterior, the Retrovisceral space, which extends to
middle mediastinum. middle mediastinum.
Extends from skull base to upper thorax Extends from skull base to upper thorax
Extends from hyoid bone down to Extends from hyoid bone down to
superior mediastinum to approx the level superior mediastinum to approx the level
of the superior aortic arch. Contains of the superior aortic arch. Contains
trachea, thyroid, parathyroids, larynx, trachea, thyroid, parathyroids, larynx,
recurrent laryngeal nerve, sympathetic recurrent laryngeal nerve, sympathetic
trunk. trunk.
The Pretracheal $pace The Pretracheal $pace
The posterior portion of the visceral compartment. The posterior portion of the visceral compartment.
Behind pharynx and upper esophagus. Behind pharynx and upper esophagus.
nterior to perivertebral space; separated by longus coli nterior to perivertebral space; separated by longus coli
muscles on imaging. muscles on imaging.
Extends from skull base to middle mediastinum. Extends from skull base to middle mediastinum.
Commmunictaes freely with paratracheal space at superior Commmunictaes freely with paratracheal space at superior
extent. Caudal to the thyroid, space is separated by extent. Caudal to the thyroid, space is separated by
connective tissue. connective tissue.
Referred to a retropharyngeal space in upper neck and Referred to a retropharyngeal space in upper neck and
retroesophageal in the middle and lower. retroesophageal in the middle and lower.
Retrovisceral $pace Retrovisceral $pace
is located lateral to visceral space
and anterior to carotid space. No
important structure is present in
is located posterior to carotid
space and lateral to perivertebral
space and contains mostly Iat.
Spinal accessorynerve and
Preaillary portion oI brachial
pleus pass through this space.
Posterior cervical space
Anterior cervical space
Visceral Compartment Visceral Compartment
natomy explains how retropharyngeal natomy explains how retropharyngeal
processes (abcess) can extend down to processes (abcess) can extend down to
into the pretracheal space to affect thyroid into the pretracheal space to affect thyroid
glands and anterior mediastinum. glands and anterior mediastinum. nd nd
explain how a goiter can extend behind the explain how a goiter can extend behind the
esophagus and grow either up as a esophagus and grow either up as a
retropharygeal mass or down as a retropharygeal mass or down as a
retroesophageal mass. retroesophageal mass.
Visceral Compartment Visceral Compartment
Pretracheal thyroid goiter extending up to retropharyngeal
spaces demonstrates free communictaion within visceral
compartment. Note respect of perivertebral space and
longus coli muscle.
Retropharyngeal abscess exending into
mediastinum (called retroesphageal space).
Visceral Compartment Visceral Compartment
Retrovisceral $pace Retrovisceral $pace
Contents Contents
Retropharyngeal space Retropharyngeal space
Pharynx Pharynx
Lymph nodes Lymph nodes
at at
Retroesophageal $pace Retroesophageal $pace
Esophagus Esophagus
at at
Thyroid goiter in pretracheal
space extening into superior
mediastinum.
Thyroid goiter extending down to
retrovisceral (retroesophageal)
space.
Thyroid goiter extends up behind pharynx
into the retropharyngeal space. (Note respect of
prevertebral space and longus coli muscle posteriorly.)
Visceral Compartment Visceral Compartment
Prevertebral $pace: Prevertebral $pace:
Vertebral body and disc Vertebral body and disc
disease disease
Muscle disease Muscle disease
$chwannoma $chwannoma
Phrenic nerve Phrenic nerve
nfection: cellulitis, abcess nfection: cellulitis, abcess
Paravertebral $pace Paravertebral $pace
Muscle disease Muscle disease
$chwannoma $chwannoma
Brachial plexus roots Brachial plexus roots
Vertebral artery aneurysm Vertebral artery aneurysm
Vertebral vein thrombosis Vertebral vein thrombosis
Metastasis Metastasis
Perivertebral $pace Masses Perivertebral $pace Masses
Metastatic lesions to the preertebral space as well as to the Metastatic lesions to the preertebral space as well as to the
carotid space can potentially determine inoperability. carotid space can potentially determine inoperability.
land tumors land tumors
Deep portion of parotid tumors Deep portion of parotid tumors
,Minor salivary gland tumors Minor salivary gland tumors
Nerves Nerves
V3 schwannomas V3 schwannomas ,$ympathetic $ympathetic
trunk disease trunk disease
Paragangliomas Paragangliomas
nfectious nfectious
Cellulitis/abcess Cellulitis/abcess
Branchial Cleft Cysts Branchial Cleft Cysts ,ygromas ygromas
Parapharyngeal $pace Masses Parapharyngeal $pace Masses
Masses originating from PPS are Masses originating from PPS are rare rare; most important use is mass ; most important use is mass
effect upon this space from Iesions arising in effect upon this space from Iesions arising in other other spaces. Acts as a spaces. Acts as a
"highway" for spread of disease. "highway" for spread of disease.
T2 MR image ..high signal parotid lymphangioma filling gland and extending
through stylomandibular tunnel into prestyliod compartment of PP$.
Parapharyngeal $pace Parapharyngeal $pace
Parapharyngeal $pace Parapharyngeal $pace
Pleomorphic adenoma displacing the internal pterygoid muscle ventrally and
widening the stylomandibular tunnel. The left parapharygeal wall is displaced
medially.
$alivary gland disease $alivary gland disease
Warthin's tumor Warthin's tumor
emangioma/lymphangioma emangioma/lymphangioma
Branchial cleft cysts Branchial cleft cysts
Epidermoids Epidermoids
Lingual and CN schwannomas Lingual and CN schwannomas
Level adenopathy Level adenopathy
acial and lingual vascular disease acial and lingual vascular disease
$ubmandibular $pace Masses $ubmandibular $pace Masses
Lateral neck Lateral neck
radiography o a radiography o a
child with loss o child with loss o
the normal the normal
cerical lordosis cerical lordosis
and marked and marked
preertebral sot preertebral sot
tissue swelling tissue swelling
due to a large due to a large
retropharyngeal retropharyngeal
abscess abscess
#etropharyngeal $pace #etropharyngeal $pace - - child child