7. anatomy of neck incuding deep neck spaces

Anatomy of neck incuding deep neck spaces

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:Areabetweenthelowerborderofmandible
aboveandsuprasternalnotchandclaviclebelow
•Complexregion:
−Passagewayforcommunicationbetweenheadand
restofthebody
•Containsvitalstructures:larynx,trachea,esophagus,
greatvessels,cranialnerves,sympathetictrunk,
spinalcord

4. Fascia and fascial spaces of Neck
•Importance
−Helpinlocalizationofneckspaceinfections
therebystoppingthespreadofinfectiontoother
areasforarelativelylongertime
−Dissectioniseasier,bettercontrolledandmore
bloodlessifitproceedsalongthefascialplanes

5. •Skin
–Containsconstantnaturallinesofcleavage
horizontally
–Incisionalongthecleavagelinegivesnarrowscar
•Superficialfascia
−Thinlayerthatenclosesplatysma,cutaneous
nerves,superficialveins,superficiallymphnodes
•Deepfascia

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)
•Thosetraversetheentirelengthoftheneck
–Retropharyngealspace,dangerspace,prevertebral
space,visceralvascularspace(carotidsheath)
•Suprahyoid
−Submandibular,parapharyngeal,peritonsillar,
masticator,parotid,temporalspace
•Infrahyoid
–Anteriorvisceralspace

10. ParapharyngealSpace
•Boundaries
−Baseand 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
•Immediatelyposteriortothenasopharynx,
oropharynx,hypopharynx,larynx,andtrachea
•Boundaries
–Buccopharyngealfasciaanteriorly
–Alarfasciaposteriorly
–Carotidsheathandparapharyngealspacelaterally
–Baseoftheskullsuperiorly
–Inferiorlytothemediastinumatthelevelofthe
trachealbifurcation

15. •Dividedintotwolateralcompartments(spaceof
Gillette)byafibrousraphe
•Eachlateralcompartmentcontainsretropharyngeal
nodeswhichusuallydisappearafter4-5yearsofage
•Communicateswiththeparapharyngealspaceand
theposteriormediastinumleadingtospreadof
infectiontotheseareas

16. •Dangerspace
−Formedanteriorlybythealarfasciaand
posteriorlybytheprevertebralfascia
−Extendsdownthemediastinumtothelevelofthe
diaphragm
•Prevertebralspace
–Boundedanteriorlybytheprevertebralfasciaand
posteriorlybythelonguscolimusclesofthespine
–Continuestotheinsertionofthepsoasmuscles

18. Submandibular space
•Boundaries
–Inferior:superficiallayerofthedeepcervical
fasciaextendingfromhyoidtothemandible
–Lateral:bodyofthemandible
–Superior:mucosaofthefloorofmouth

19. Subdivisions
•Divided by the myelohyoid muscle into
•Sublingualspace(Supramyelohyoid)
–Containssublingualgland,hypoglossalnerveand
Wharton’sduct
–Continuouswiththesubmaxillaryspaceviathe
posteriormarginofthemyelohyoidmuscle
•Submaxillaryspace(Inframyelohyoid)

22. Triangles of Neck

23. Anterior triangle
•Anteriorly-midlineofneck
•Posteriorly-anteriorborderofSternocleidomastoid
•Superiorly-lowerborderofmandible
•Floor-myelohyoid,hyoglossus
•Subdividedbybelliesofdigastricandomohyoid
musclesintosubmental,submandibular,carotid,
musculartriangles

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
•AnteriorlybyposteriorborderofSCM
•Posteriorlybytrapezius
•Inferiorly-middle3
rd
ofclavicle
•Floor-deeplayerofdeepcervicalfascia
•Roof-superficiallayerofdeepcervicalfascia
•Subdividedtooccipitalandsubclavianby
posteriorbellyofomohyoidmuscle

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
cervicalnodes)
•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