Anatomy of neck, deep neck spaces

general anatomy and lymphatic drainage of neck

1. General anatomy and
Lymphatic drainage of Neck
Dr. Krishna Koirala
MBBS, MS (ENT-HNS)
2020/02/10

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

3. Fascia and fascial spaces of Neck
•Importance
−Localizationandspreadofneckspaceinfections
isdependentuponthefacialplanes
−Dissectioniseasier,bettercontrolledandmore
bloodlessifitproceedsalongthefascialplanes

4. •Skin
–Containsconstantnaturallinesofcleavage
horizontally
–Incisionalongthecleavagelinegivesnarrowscar
•Superficialfascia
−Thinlayerthatenclosesplatysma,cutaneous
nerves,superficialveins,superficiallymphnodes
•Deepfascia
–Investinglayer,Viscerallayer,Internallayer

5. •Investing layer
•Superiorly attached to the nuchal line, mastoid
process and mandible
•Inferiorly attached to the spine of C7, clavicle and
manubrium
•Splits to surround trapezius and sternomastoid
•Forms sheaths to parotid and submandibular gland
, carotid sheath and cranial nerves

6. Superior nuchal line of occipital
bone (a)
Spinous processes of cervical
vertebrae and nuchal
ligament(b)
Mastoid processes of temporal
bones(c)
Zygomatic arches(d)
Inferior border of mandible(e)
Hyoid bone(f)
Manubrium(g)
Clavicles(h)
Acromion(i)
Folds to form the stylomandibular
ligament(j)

7. •Middlelayer(Twosubdivisions)
−Musculardivisionsurroundstheinfrahyoidstrap
muscles
−Visceraldivisionenvelopsthepharynx,larynx,
esophagus,trachea,andthyroidgland
•DeepLayer(Prevertebralfascia)
−Surroundsdeepmusclesofneck
−Cervicalsympathetictrunkliessuperficialtofascia
−Cervicalplexus,phrenicnerveandbrachialplexus
liedeeptofascia

13. Deep Neck Spaces
•Describedinrelationtothehyoidbone
•Thosetraversetheentirelengthoftheneck
–Retropharyngealspace,Dangerspace,Prevertebral
space,Visceralvascularspace(Carotidsheath)
•Suprahyoid
−Submandibularspace,Parapharyngealspace,
Peritonsillar,Masticator,Parotid,Temporalspace
•Infrahyoid
–Anteriorvisceralspace

14. 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

15. Parapharyngeal Space

16. •Subdivisions (Compartments) and contents
−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

17. Retropharyngeal space
•Immediatelyposteriortothenasopharynx,
oropharynx,hypopharynx,larynx,andtrachea
•Boundaries
–Buccopharyngealfasciaanteriorly
–Alarfasciaposteriorly
–Carotidsheathandparapharyngealspacelaterally
–Baseoftheskullsuperiorly
–Inferiorlytothemediastinumatthelevelofthe
trachealbifurcation

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

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

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

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

25. Triangles of Neck

29. 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

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

31. Posterior Triangle
•AnteriorlybyposteriorborderofSCM
•Posteriorlybytrapezius
•Inferiorly-middle3
rd
ofclavicle
•Floor-deeplayerofdeepcervicalfascia
•Roof-superficiallayerofdeepcervicalfascia
•Subdividedtooccipitalandsubclavianby
posteriorbellyofomohyoidmuscle

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

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

34. 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)

36. 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

37. 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

38. 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

39. •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