Deep neck spaces are potential spaces located between layers of cervical fascia. Infections can spread between these spaces through direct extension or lymphatic drainage. Common sites of infection include the retropharyngeal space, parapharyngeal space, submandibular space, and peritonsillar space. Odontogenic infections are a frequent cause of submandibular space infections, while tonsillitis can lead to peritonsillar abscesses. Understanding the anatomy of the neck spaces is important for diagnosing and properly treating neck infections.
5. Cervical Fascia
Superficial Layer of the
Deep Cervical Fascia
(rule of two’s)
Muscles
Sternocleidomastoid
Trapezius
Glands
Submandibular
Parotid
Spaces
Posterior Triangle
Suprasternal space of
Burns
6. Cervical Fascia
Middle Layer of the
Deep Cervical Fascia
Muscular Division
Infrahyoid Strap
Muscles
Visceral Division
Pharynx, Larynx,
Esophagus, Trachea,
Thyroid
Buccopharyngeal
Fascia
7. Cervical Fascia
Deep Layer of Deep
Cervical Fascia
Alar Layer
Posterior to visceral
layer of middle fascia
Anterior to
prevertebral layer
Prevertebral Layer
Vertebral bodies
Deep muscles of the
neck
8. Cervical Fascia
Carotid Sheath
Formed by all three
layers of deep fascia
Contains carotid
artery, internal
jugular vein, and
vagus nerve
“Lincoln’s
Highway”
9. Deep Neck Spaces
Described in
relation to the
hyoid
Entire length of
the
neck
Suprahyoid
Infrahyoid
10. Deep Neck Spaces
Entire Length of Neck:
Superficial Space
Surrounds platysma
Contains areolar tissue,
nodes, nerves and vessels
Involved with cellulitis
and superficial abscesses
11. Deep Neck Spaces
Entire Length of
Neck:
1.Retropharyngeal
Space
Posterior to pharynx
and esophagus
Anterior to alar layer
of deep fascia
Extends from skull
base to T1-T2
12. Deep Neck Spaces
Entire Length of Neck:
2.Danger Space
Anterior border is alar layer
of deep fascia
Posterior border is
prevertebral layer
Extends from skull base to
diaphragm and is so named
because it contains loose
areolar tissue and offers little
resistance to the spread of
infection.
13. Deep Neck Spaces
Entire Length of Neck:
3.Prevertebral Space
Anterior border is
prevertebral fascia
Posterior border is vertebral
bodies,ALL and deep neck
muscles
Extends along entire length
of vertebral column.
Infection in this space tends
to stay somewhat localized
due to the dense fibrous
attachments between the
fascia and the deep muscles.
14. Deep Neck Spaces
Entire Length of Neck:
4.Visceral Vascular Space
Carotid Sheath
Like the prevertebral space the
visceral vascular space is quite
compact, contains little areolar
tissue and is resistant to the
spread of infection. It is
termed the “Lincolin’s
highway” of the neck . It
extends from the base of skull
into the mediastinum and
because it receives
contributions from all three
layers of deep fascia it can
become secondarily involved
by infection in any other deep
neck space by direct spread.
15. Deep Neck Spaces
Suprahyoid:
1.Submandibular Space
Anterior/Lateral—
mandible
Superior—mucosa
Inferior—superficial layer
of deep fascia
Posterior/Inferior--hyoid
16. Deep Neck Spaces
Suprahyoid: Submandibular
Space comprises
Sublingual Space
Areolar tissue
Hypoglossal and lingual nerves
Sublingual gland
Wharton’s duct
Submylohyoid Space
Anterior bellies of digastrics
Submandibular gland
(These two subdivisions freely
communicate around the
posterior border of the
mylohyoid. )
17. Deep Neck Spaces
Suprahyoid: 2.Parapharyngeal
Space (pharyngomaxillary space )
Superior—skull base-petrous
portion of temporal bone vs.
sphenoid
Inferior—hyoid
Anterior—ptyergomandibular
raphe
Posterior—prevertebral fascia
Medial—buccopharyngeal fascia
Lateral—superficial layer of deep
fascia,medial pterygoid and
parotid .
The parapharyngeal space
communicates with
submandibular , retropharyngeal,
parotid and masticator spaces
with important implications in
spread of infection .
18. Deep Neck Spaces
Suprahyoid: Parapharyngeal
Space comprises:
Prestyloid
Medial—tonsillar fossa
Lateral—medial pterygoid
Contains fat, connective tissue,
nodes
Poststyloid
Carotid sheath
Cranial nerves IX, X, XII
The stylopharyngeal aponeurosis
of Zuckerkandel is formed by the
intersection of the alar,
buccopharyngeal and
stylomuscular fascia and acts as a
barrier to the spread of infection
from the prestyloid compartment
to the poststyloid compartment.
19. Relations to other spaces
Normal anatomy of parapharyngeal space.
BS = buccal space, ICA = internal carotid
artery, IJV = internal jugular vein, MS =
masticator space, PMS = pharyngeal
mucosal space, PPS = parapharyngeal space,
PS = parotid space, PVS = prevertebral
space, RPS = retropharyngeal space, SMS =
submandibular space, T = torus tubarius.
Axial schematic at nasopharynx level shows
that parapharyngeal space is divided into
prestyloid and poststyloid compartments by
tensor-vascular-styloid fascia connecting
tensor veli palatini muscle with styloid
process.
20. Deep Neck Spaces
Suprahyoid: Peritonsillar Space
Medial—capsule of palatine
tonsil
Lateral—superior pharyngeal
constrictor
Superior—anterior tonsil pillar
Inferior—posterior tonsil pillar.
This space contains loose
areolar tissue, primarily in the
area adjacent to the soft palate,
which explains why the
majority of peritonsillar
abscesses will localize to the
superior pole of the tonsil.
21. Deep Neck Spaces
Suprahyoid:3.Masticator and
Temporal Spaces
Formed by the superficial layer
of deep cervical fascia and
contains.
Masseter and pterygoids
Temporalis.
The masticator space is in direct
communication with the temporal
space superiorly deep to the
zygoma. The temporal space has
as its lateral boundary the
superficial layer of deep fascia
and its medial boundary the
periosteum of the temporal bone.
It is subdivided into superficial
and deep spaces by the body of
the temporalis muscle. This
space contains the internal
maxillary artery and the
mandibular nerve.
22. Deep Neck Spaces
Suprahyoid:4. Parotid Space
Formed by superficial layer
of deep fascia and dense
septa from capsule into
gland.
In addition to the parotid
gland, this space contains
the parotid lymph nodes,
the facial nerve and
posterior facial vein.
The fascial envelope is
deficient on the supero-
medial surface of the gland,
facilitating direct
communication between
this space and the
parapharyngeal space.
23. Deep Neck Spaces
Infrahyoid: Anterior
Visceral Space
Formed by middle layer of
deep fascia
Contains thyroid, trachea,
esophagus. This potential
space runs from the thyroid
cartilage into the anterior
superior mediastinum to the
arch of the aorta. Below the
level of the thyroid gland
this space communicates
laterally with the
retropharyngeal space .
25. Pathophysiology
Deep neck space infections can arise from a
multitude of causes., as follows:
1. Spread of infection can be from the oral cavity,
face, or superficial neck to the deep neck space via
the lymphatic system.
2. Lymphadenopathy may lead to suppuration and
finally focal abscess formation.
3. Infection can spread among the deep neck spaces
by the paths of communication between spaces.
4. Direct infection may occur by penetrating trauma.
26. Spread of infection
Tonsillitis may lead to peritonsillar abscess. If not
treated successfully, peritonsillar abscess may
spread to the lateral pharyngeal space. From thereto
the posterior pharyngeal and prevertebral spaces
and into the chest. Mediastinitis and empyema may
ensue.
Alternatively, infection may spread from the lateral
pharyngeal space to the contents of the carotid
sheath, leading to internal jugular vein thrombosis,
subacute bacterial endocarditis, pulmonary emboli,
carotid artery thrombosis cerebrovascular
insufficiency, Horner syndrome ,or may cause even
airway obstruction .
27. Retropharyngeal Abscess
50% occur in patients 6-12 months of age
96% occur before 6 years of age
Retropharyngeal phlegmon.
Axial CT section through the
lower nasopharynx shows a
well-marginated lucent area in
the
retropharyngeal/parapharynge
al space with an enhancing
wall and surrounding edema
28. Adults
Pediatrics
Cause—trauma,
Cause—suppurative instrumentation,
process in lymph nodes extension from
Nose, adenoids, adjoining deep neck
nasopharynx, sinuses
space
29. Danger Space
Cause—extension from retropharyngeal,
prevertebral or parapharyngeal space
Can extend to mediastinum .
30. Prevertebral Space
Back, shoulder, neck
pain
made worse by
deglutition
Dysphagia or
dyspnea
Cause—Pott’s
abscess, trauma,
osteomyelitis,
extension from
retropharyngeal and
danger spaces
32. Visceral Vascular Space
Induration and tenderness over SCM
Torticollis toward opposite side
Spiking fevers, sepsis
Cause—intravenous drug abuse, extension from
other deep neck spaces
33. Submandibular Space
Anterior neck swelling,
floor of mouth edema
Cause—70-85% have
odontogenic origin
First molar and
anterior
Second and third
molars
Sialadenitis,
lymphadenitis,
mandible fractures,etc.
Right submandibular gland
infection with a stone
34. Which space is affected ?
The apex of the first molar is
above the mylohyoid, so
involvement of this tooth, or
teeth anterior to this, will first
involve the sublingual space. In
contrast, the apices of the
second and third molars are
below the mylohyoid and
infection here will first spread to
the submylohyoid space.
However, as previously
mentioned, these spaces freely
communicate around the
posterior border of the
mylohyoid, and both subspaces
may be involved.
35. Ludwig’s
angina
Tender, firm anterior neck
edema without fluctuance
Contrast CT scan through the tongue and oral cavity
demonstrates an enhancing inflammatory mass with abscess
in the right tongue and oral cavity with extension into the
parapharyngeal space and masticator space.
36. Ludwig's angina. Axial CT
section through the tongue
demonstrates diffuse
enlargement of the tongue
associated with low
attenuation areas consistent
with phlegmon.
37. Parapharyngeal
Space
Cause—infection
of pharynx, tonsil,
adenoids,
dentition, parotid,
mastoid,
suppurative
lymphadenitis,
extension from
other deep neck
spaces
38. Middle ear infections
or mastoiditis may
involve the
parapharyngeal space
after rupture of a
Bezold’s abscess on
the inner aspect of the
mastoid tip along the
digastric ridge.
. Bezold's abscess, upper left neck. A, Axial
noncontrast CT section defines an ill-defined
mass in the upper posterior left neck. B, Axial
CT section (bone window setting) demonstrates
lytic destruction in the lower left mastoid
secondary to coalescent mastoiditis.
39. Peritonsillar Space
Fever, malaise
“Hot-potato” voice,
trismus.
Cause—extension
from tonsillitis.
These infections are
uncommon in the
pediatric population,
but instead tend to
effect post-pubescent
individuals.
CT section demonstrates an enhancing mass in
the right peritonsillar region with a low-
attenuation area centrally consistent with an
abscess cavity
40. Masticator
Temporal Space
Swelling along
ramus of mandible Parotid Space
Cause— Medial bulge
odontogenic, from of posterior
third molars lateral
pharyngeal
wall
Cause—
parotitis,
sialolithiasis,
Sjogren’s
syndrome
41. Right neck
abscess with
extension to
the
masticator
space
42. Internal Jugular Vein Thrombosis
Complications
Lemierre’s syndrome
F/C, prostration, swelling and
pain along SCM
Bacteremia, septic embolization,
dural sinus thrombosis
Pulmonary embolism
occurs in up to 5% of
these patients.
Patients that develop
deep neck infection
secondary to
intravenous drug
abuse.
Right jugular vein thrombosis. Axial CT
section through the neck below the angle
of the mandible demonstrates a low
attenuation area with an enhancement
wall in the right neck medial to the
indistinct and enlarged
sternocleidomastoid muscle.
43.
44. Complications
Carotid Artery Rupture
Mortality of 20-40%
Sentinel bleeds from ear, nose, mouth
Majority from internal carotid, less from external
carotid, and fewest from common carotid
45. Complications
Mediastinitis
A- MDCT of the neck shows
two large fluid collections
containing gas in both the
submandibular spaces
(arrows).(B) At the level of the
hyoid bone, a large fluid
collection is seen in the
visceral space (C) Large fluid
collection in the visceral space
(D) The fluid collection
spreads to the anterior
mediastinum (E) Sagittal
multiplanar reformatted CT
image shows spread of
descending necrotizing
mediastinitis
46. Special Consideration
Recurrent Deep Neck
Space Infection
THINK CONGENITAL
ABNORMALITY
Nusbaum, et al: 12 cases of
recurrent deep neck infection
Most Common: second branchial
cleft cyst
Others: first, third, fourth branchial
cleft cysts, lymphangiomas,
thyroglossal duct cysts, cervical
thymic cyst
Infected right branchial cleft cyst. CT scan shows an
oval-shaped lucent area in the right neck at the level
of the upper thyroid cartilage