DEEP NECK SPACE ANATOMY

1. Dr. Ajay Manickam
MS (ENT) JUNIOR RESIDENT
R.G.Kar Medical College

2. 
 Extension
 Anteriorly from lower border of mandible to upper
surface of manubrium of sternum
 Posteriorly from superior nuchal line on occipital
bone of skull to c7 and t1 vertebrae
Introduction

3. 
 Skin – cervical
dermatome
 Muscles – cervical
myotomes
 The branchial
apparatus
Developmental
Anatomy

4. 
 4 compartments provide longitudinal organisation
 Visceral compartment – anterior – digestive,
respiratory & endocrine glands
 Vertebral compartment – posterior – cervical
vertebrae, spinal cord, cervical nerves and muscles
 2 vascular compartments – lateral – major blood
vessels and vagus nerve
Compartments

5. 
Fascia
Superficial
Deep
1.Superficial layer
2.Middle layer
3. Deep laayer
Fascial layers

6. 
 Thin sheet of muscle
platysma, begins in
superficial fascia of thorax,
attaches to mandible and
blend with muscles of face
 Penetrated by blood vessel
that supply neck skin
 Subplatysmal flap protects
blood supply to the skin
 Facial nerve- cervical branch
Superficial fascia

7. 
 Superficial layer
 Arises from ligamentum nuchaeand spinous process
of cervical vertebrae
 Splits to enclose
trapezius,omohyoid,sternocleidomastoid,strap
muscles and parotid gland
Deep cervical fascia

8. 
 Middle layer
 Derived from superior layer of deep
cervical fascia encircles trachea,
thyroid, esophagus
 A. Investing Layer
 B. Muscular Pretracheal Layer
 C. Visceral Pretracheal Layer
 D. Prevertebral Layer
Deep cervical fascia

9. 
 Deep layer
 Arise from ligamentum
nuchaeand spinous process of
cervical vertebra
 Splits to enclose postvertebral
muscles, form layer over
vertebrae
 Floor of post triangle
 Allows pharynx to glide during
deglutition
 Extends in lower region of neck
to axilla – axillary sheath
Deep cervical fascia

10. 
 Superficial layer of cervical fascia medial to
sternocleidomastoid muscle
 Contains 80% LN,carotid artery, IJV,vagus nerve
Carotid sheath

11. 
Triangles of neck

12. 
Fascial spaces
Between the fascial layers in the neck
are spaces that may provide conduit for
the spread of infections
They contain loose areolar fascia

13. 
 Deep Neck Spaces are described in relation to the
Hyoid bone.
 A. Entire length of the neck.
 B. Suprahyoid.
 C. Infrahyoid.
Classification of neck
spaces

14. 
 1. Superficial neck space
 2. Deep neck spaces
Retropharyngeal space
Danger space of Gillette
Pre vertebral space
Involving entire length
of neck

15. 
 Sub mental space
 Submandibular space
-Sublingual space
-Sub maxillary space
 Peri tonsillar space
 Parotid space
 Para pharyngeal space
 Masticator space
Supra-hyoid

16. 
 Pretracheal space
Infra hyoid

17. 
 Extends from base of skull to
tracheal bifurcation
 Between two parapharyngeal space
 Superior – skull base
 Anterior – musculature of pharynx
 Posteror limit – prevertebral fascia
 Communicates with – mediastinum
 It is divided into two lateral
compartments space of gillete by
fibrous raphe
Retropharyngeal space

18. 
 There are a group of inconsistent nodes in the
retropharyngeal space known as the Glands of Henle
which regresses by 5 yrs of age. Suppuration of these
nodes result in Ac. Retropharyngeal abscess and thus
commoner in children.
 There is also a constant group of nodes called the
Rouvier’s nodes which are the first nodes to enlarge
in cases of nasopharyngeal and posterior sinus
malignancies.
Retropharyngeal space

19. 
 Base of skull to diaphragm
 Located between the pre vertebral fascia and alar
fascia
 Retro pharyngeal space proper is in front of alar
fascia
 This is called danger space because of easy route of
mediastinitis
Danger space

20. 
 Potential space between cervical vertebra posteriorly and
the prevertebral fascia anteriorly
 Extends from base of skull to coccyx
 Tuberculosis of spine, penetrating traumas chief source of
infections
Prevertebral space

21. 
 Midline space between anterior bellies of digastric
muscles
 Contents – areolar tissue, lymphnode, ant jugular
vein
Submental space

22. 
 Includes submaxillary + sublingual,
divided by mylohyoid muscle
 Superficial boundary – submandibular
gland & digastric muscle
 Deep boundary – mylohyoid muscle
 Lies between mucous membrane of
floor of mouth& tongue on oneside &
superficial layer of deep cervical fascia,
from mandible to hyoid bone
 Comunicates with floor of the mouth
Submandibular space

23. 
 Between capsule of tonsil & superior constrictor
 Located lateral to the tonsils
 Infection source is mainly tonsillar crypts
 Communicates with retropharyngeal &
parapharyngeal space
Peritonsillar space

24. 
 Boundaries
The space is circumscribed by the superficial layer of the deep cervical
fascia
superior margin: external auditory canal; apex of the mastoid process
inferior margin: inferior mandibular margin (although the parotid tail can
extend further inferiorly below the angle of the mandible)
anterior margin: masticator space
 contents
parotid glands
parotid lymph nodes
facial nerve (CN VII)
external carotid artery
retromandibular vein
Fascial layer is very thick superficially , very thin on deep side of gland- burst
to parapharyngeal space- mediastinum
Parotid space

25. 
 Inverted pyramid shaped
Para pharyngeal space

26. 
 Located between superficial layer of deep
cervical fascia & muscles of mastication
 Extends from base of skull to lower border
of mandible
 Contents
muscles of mastication
ramus and body of mandible
inferior alveolar nerve,vein,artery
mandibular division of the trigeminal nerve
(V3)
enters the masticator space via the foramen
ovale
Masticator space

27. 
 Anterior and lateral to thyroid cartilage
 Contains delphian node
 Communicates – superior mediastinum
Pretracheal space

28. 
Neck nodes

29. 

30. 
Neck space infections

31. 
 Rare, but life threatening infection,that causes
progressive necrosis of the subcutaneous fat and
fascia and causes secondary necrosis of the overlying
skin.
 ETIOLOGY - Odontogenic infections
- Tonsillar infections
- As a complication of other DNSI
Necrotizing fascitis

32. 
 Cellulitis with disproportionate pain.
 Reduced skin sensation of the involved areas.
 Outer zone- Erythema
Intermediate zone- Tender ecchymosis
Central zone- Vesiculation
 Soft tissue crepitus due to gas formation.
 Hypocalcemia , Hyponatremia , Dehydration
Necrotizing fascitis

33. 
 Early correction of fluid and
electrolyte imbalance.
 I.V Penicillin and I.V Metronidazole
are the mainstays of the antimicrobial
therapy.
 Surgical debridement of all necrotic
areas is the key to successful
treatment of the patient.
 Skin grafting after wound
debridement
Necrotizing fascitis

34. 
 Life threatening
infection
 URI, tuberculous
lymphadenitis
 X-Ray soft tissue neck
lateral view, CT
 Incision & drainage
Retropharyngeal space
infections

35. 
 Children <3yDysphagia and difficulty in breathing.
 Stridor and Croupy cough maybe present,Torticollis,Bulge in the posterior
pharyngeal wall.
 The child is febrile and adopts a
peculiar posture with the neck
flexed and the head extended.
 Straightening of the cervical
spine known as Ramrod Spine
Radiographic picture of the lateral
view of neck (soft tissue) shows
widening of the prevertebral
space and even the presence of
gas shadows(air fluid levels).
Acute retropharyngeal
abscess

36. 
 Incision and Drainage of abscess is done,usually without
anaesthesia as there is risk of rupture during intubation.[the child
is kept supine with head low and mouth opened with a gag.A
vertical incision is given in the most fluctuant area.Suction should
always be available to prevent aspiration]
 Systemic Antibiotics-Broad spectrum antibiotics like Ceftriaxone
and Metronidazole may be used.
 Tracheostomy in airway obstruction
Acute retropharyngeal
abscess

37. 
 TB Spine(Pott’s Spine) where the pus collects in the
prevertebral space.
 TB of retropharyngeal lymph nodes present in the
retropharyngeal space proper.
 Post traumatic-vertebral fracture.
 Spread from Parapharyngeal abscess
Chronic retropharyngeal
abscess

38. 
 Discomfort in the throat,mild dysphagia.
 Pain is absent due to cold abscess.
 Bulge in the posterior pharyngeal wall
either centrally or laterally.
 Neck may show Tubercular lymph nodes.
 Treatment - Incision and drainage of
abscess is done through a vertical incision
along the anterior border of the
sternocleidomastoid for low abscesses, or
along its posterior border for high
abscesses.
 Full course of anti-Tubercular therapy is
given
Retropharyngeal space
infections

39. 
 Odontogenic infection – submandibular space –
submental region
 Mandibular fractures
 Cutaneous infection
 Treatment- I&D
Sub mental abscess

40. 
 Drooling, trismus,
dysphagia, stridor caused by
laryngeal edema, and
elevation of the posterior
tongue against the palate ,
fever, tachycardia.
 Aerobe, anaerobe
 Maintanence of airway
 Needle aspiration USG or CT
guided
Submandibular space
infection

41. 
 Toothache, fever, odynophagia, drooling.
 SUBLINGUAL space infection
-floor of mouth swelling.
-tongue elevation.
 SUBMAXILLARY space infection
-brawny/woody tender swelling below the chin.
 Trismus.
 Stridor- due to falling back of tongue, laryngeal edema.
 Initially there is cellulitis which is followed by abscess
formation.
Submandibular space
infection

42. 
Ludwig’s angina
Xray showing
supraglottic swelling

43. 
 Systemic antibiotics- Ceftriaxone/Cefuroxime and
Metronidazole/Clindamycin.
 Tracheostomy if airway is compromised after unsuccessful
attempts at oral/nasal intubations.
 Incision and Drainage of Abscess:
intraoral—sublingually localised infection.
extraoral—submaxillary infection.
 A transverse incision extending from one angle of mandible to
the other is made with vertical opening of midline musculature
of tongue with a blunt haemostat
Ludwig’s angina

44. 
 Quinsy
 Tonsillitis
 Odynophagia, hot
potato voice
 Complication –
ludwig’s angina,
adjacent spaces
 Needle aspiration
 I&D
Peri tonsillar space
infection

45. 
 Peritonsillar abscess is opened at the
point of maximum bulge above the
upper pole or just lateral to the point
of junctionof anterior pillar and a
horizontal line drawn through the
base of the uvula
 Interval Tonsillectomy maybe done 4 to
6 weeks after an attack of Quincy.
 Abscess/Hot Tonsillectomy are preffered
by some instead of Incision and
drainage. This has the risk of abscess
rupture during anaesthesia and
excessive bleeding at the time of
operation.
Incision & drainage

46. 
 Acute/Chronic infections of tonsils and adenoid,
bursting of the peritonsillar abscess.
 Dental infection usually from the lower last molar.
 From Bezold abscess or Petrositis.
 Infections of parotid, retropharyngeal and
submaxillary spaces.
 Penetrating injuries of neck, injection of L.A for
mandibular nerve block or for tonsillectomy.
Parapharyngeal space
infections

47. 
 More common in adults
 Infective process of upper
aerodigestive tract,
 Trismus, pyrexia, tonsil may
be medially displaced
 USG, CT, needle aspiration
under CT or USG guidance
 Small loculated –
conservatively
 Large collections – external
approach, medial to carotid
sheath, isertion of a drain
Parapharyngeal space
infections

48. 
 Incision and Drainage
 -Usually done under G.A.
 -Pre-op tracheostomy if trismus is marked.
 -Drained by a horizontal incision made 2-3 cms below
the angle of the mandible.Blunt dissection is done along
the inner surface of the medial pterygoid towards styloid
process and the abscess is evacuated and a drain is
inserted.
 [Transoral drainage should never be done due to the
danger of the great vessels which pass through this
space.]
Parapharyngeal space
infection

49. 
 Causes
 Ascent of bacterial
infection(Staphylococcus,
Streptococcus,Haemophilus) to a
dehydrated parotid via Stenson’s duct
from oral cavity.
 Suppuration of intra-parotid LNs.
 Spread of infection from the auditory
canal via the cartlaginous fissures of
Santorini or the bony foramen of Huschke.
Parotid space infection

50. 
 Symptoms
Spontaneous onset of painful parotid
enlargement followed by fever and
cellulitis which then turns into fluctuant
parotid abscess.
Pain and induration over the parotid.
Pitting edema over the parotid area
differentiates parotid abscess from
simple parotitis
Parotid massage expresses pus into the
oral cavity via the Stenson’s duct
,opposite the upper 2nd molar.
Parotid space infection

51. 
Treatment:-
Maintainence of oral hygiene, IV antibiotics
Incision and Drainage:-
 -Blair’s incision made.
 -Multiple incisions made through fascia parallel to
branches of the facial nerve.
 -Blunt dissection done to evacuate the pus.
 -Drains are placed.
Parotid space

52. 