Moore` s clinically oriented anatomy

The deep cervical fascia consists of three fascial layers (sheaths): investing, pretracheal, and
prevertebral. These layers support the cervical viscera (e.g., thyroid gland), muscles, vessels, and deep
lymph nodes. The deep cervical fascia also condenses around the common carotid arteries, internal jugular
veins (IJVs), and vagus nerves to form the carotid sheath.
These three fascial layers form natural cleavage planes through which tissues may be separated during
surgery, and they limit the spread of abscesses (collections of pus) resulting from infections. The deep
cervical fascial layers also afford the slipperiness that allows structures in the neck to move and pass over
one another without difficulty, such as when swallowing and turning the head and neck.

INVESTING LAYER OF DEEP CERVICAL FASCIA

The investing layer of deep cervical fascia, the most superficial deep fascial layer, surrounds the entire
neck deep to the skin and subcutaneous tissue. At the “four corners” of the neck, it splits into
superficial and deep layers to enclose (invest) the trapezius and sternocleidomastoid (SCM)
muscles. These muscles are derived from the same embryonic sheet of muscle and are innervated by the
same nerve (CN XI). They have essentially continuous attachments to the cranial base superiorly and to the
scapular spine, acromion, and clavicle inferiorly.
Superiorly, the investing layer of deep cervical fascia attaches to the:
• Superior nuchal lines of the occipital bone. • Inferior border of the mandible.
• Mastoid processes of the temporal bones. • Hyoid bone.
• Zygomatic arches. • Spinous processes of the cervical vertebrae.
Just inferior to its attachment to the mandible, the investing layer of deep fascia splits to enclose the
submandibular gland; posterior to the mandible, it splits to form the fibrous capsule of the parotid
gland. The stylomandibular ligament is a thick modification of this fascial layer.
Inferiorly, the investing layer of deep cervical fascia attaches to the manubrium of the sternum,
clavicles, and acromions and spines of the scapulae. The investing layer of deep cervical fascia is
continuous posteriorly with the periosteum covering the C7 spinous process, and with the nuchal
ligament (L. ligamentum nuchae), a triangular membrane that forms a median fibrous septum between the
muscles of the two sides of the neck. Inferiorly between the sternal heads of the SCMs and just superior to
the manubrium, the investing layer of deep cervical fascia remains divided into two layers to enclose the
SCM; one-layer attaches to the anterior and the other to the posterior surface of the manubrium. A
suprasternal space lies between these layers. It encloses the inferior ends of the anterior jugular veins, the
jugular venous arch, fat, and a few deep lymph nodes.
PRETRACHEAL LAYER OF DEEP CERVICAL FASCIA
The thin pretracheal layer of deep cervical fascia is limited to the anterior part of the neck. It extends
inferiorly from the hyoid into the thorax, where it blends with the fibrous pericardium covering the heart.
The pretracheal layer of fascia includes a thin muscular part, which encloses the infrahyoid
muscles, and a visceral part, which encloses the thyroid gland, trachea, and esophagus, and is
continuous posteriorly and superiorly with the buccopharyngeal fascia of the pharynx.
The pretracheal layer of deep fascia blends laterally with the carotid sheaths. Superior to the hyoid, a
thickening of the pretracheal fascia forms a pulley or trochlea through which the intermediate tendon of the
digastric muscle passes, suspending the hyoid. By wrapping around the lateral border of the intermediate
tendon of the omohyoid, the pretracheal layer also tethers the two-bellied omohyoid muscle, redirecting the
course of the muscle between the bellies.

PREVERTEBRAL LAYER OF DEEP CERVICAL FASCIA

The prevertebral layer of deep cervical fascia forms a tubular sheath for the vertebral column and the
muscles associated with it, such as the longus colli and longus capitis anteriorly, the scalenes laterally, and
the deep cervical muscles posteriorly (Fig. 8.4A & B). The prevertebral layer of deep fascia is fixed to
the cranial base superiorly. Inferiorly, it blends with the endothoracic fascia peripherally and fuses
with the anterior longitudinal ligament centrally at approximately the T3 vertebra (see Chapter 4)
(Fig. 8.4A). The prevertebral fascia extends laterally as the axillary sheath (Chapter 6), which
surrounds the axillary vessels and brachial plexus. The cervical parts of the sympathetic trunks are
embedded in the prevertebral layer of deep cervical fascia.
Carotid Sheath is a tubular fascial investment that extends from the cranial base to the root of the neck.
This sheath blends anteriorly with the investing and pretracheal layers of fascia and posteriorly with the
prevertebral layer of fascia (Fig. 8.4B & C). The carotid sheath contains the:
• Common and internal carotid arteries. • Carotid sinus nerve.
• Internal jugular vein. • Sympathetic nerve fibers (carotid peri-arterial
• Vagus nerve (CN X). plexuses).
• Some deep cervical lymph nodes.
The carotid sheath and pretracheal fascia communicate freely with the mediastinum of the thorax inferiorly
and the cranial cavity superiorly. These communications represent potential pathways for the spread of
infection and extravasated blood.

Retropharyngeal Space. The retropharyngeal space is a midline deep compartment of the head and
neck that consists largely of fatty areolar tissue and lymph nodes that drain the pharynx, nose, and middle
ear. The retropharyngeal space is the largest and most important interfascial space in the neck. It is a
potential space that consists of loose connective tissue between the visceral part of the prevertebral layer of
deep cervical fascia and the buccopharyngeal fascia surrounding the pharynx superficially. Inferiorly, the
buccopharyngeal fascia is continuous with the pretracheal layer of deep cervical fascia.
The retropharyngeal space is posterior to the pharynx and esophagus, and extends from the base of the
skull to the thoracocervical junction as the alar fascia attaches to the buccopharyngeal fascia (at a variable
level between the C6 and T6 vertebral bodies) . The main component of the retropharyngeal space is areolar
fat. Lymph nodes are found in the portion of the retropharyngeal space above the hyoid bone, and these
lymph nodes drain the pharynx, nasal cavity, paranasal sinuses and middle ears. These lymph nodes are
prominent in children, and atrophy with age. Contents; areolar fat; retropharyngeal lymph nodes and small
vessels.

The alar fascia forms a further subdivision of the retropharyngeal space. This thin layer is attached along
the midline of the buccopharyngeal fascia from the cranium to the level of the C7 vertebra. From this
attachment, it extends laterally and terminates in the carotid sheath. The retropharyngeal space permits
movement of the pharynx, esophagus, larynx, and trachea relative to the vertebral column during
swallowing. This space is closed superiorly by the cranial base and on each side by the carotid sheath. It
opens inferiorly into the superior mediastinum.
The alar fascia is a thin fibroareolar membrane separating the (anterior) true retropharyngeal space from the
(posterior) danger space. It is the ventral component of the deep layer of the deep cervical fascia. location:
between the visceral and prevertebral fascia, Cranially, it reaches the skull, and caudally, it reaches the
second thoracic vertebra.

The investing layer of deep cervical fascia helps prevent the spread of abscesses (purulent infections)
caused by tissue destruction. If an infection occurs between the investing layer of deep cervical fascia
and the muscular part of the pretracheal fascia surrounding the infrahyoid muscles, the infection will
usually not spread beyond the superior edge of the manubrium of the sternum. If, however, the
infection occurs between the investing fascia and the visceral part of pretracheal fascia, it can spread
into the thoracic cavity anterior to the pericardium.
Pus from an abscess posterior to the prevertebral layer of deep cervical fascia may extend laterally
in the neck and form a swelling posterior to the SCM. The pus may perforate the prevertebral layer
of deep cervical fascia and enter the retropharyngeal space, producing a bulge in the pharynx
(retropharyngeal abscess). This abscess may cause difficulty in swallowing (dysphagia) and
speaking (dysarthria).
Infections in the head may also spread inferiorly posterior to the esophagus and enter the posterior
mediastinum, or it may spread anterior to the trachea and enter the anterior mediastinum. Infections
in the retropharyngeal space may also extend inferiorly into the superior mediastinum. Similarly, air
from a ruptured trachea, bronchus, or esophagus (pneumomediastinum) can pass superiorly in the
neck.
Summary:
There are two fascias in the neck – the superficial cervical fascia and the deep cervical fascia. The
superficial cervical fascia lies between the dermis and the deep cervical fascia. It contains numerous
structures: Neurovascular supply to the skin, Superficial veins (e.g. the external jugular vein),
Superficial lymph nodes, Fat, Platysma muscle
The platysma is a broad superficial muscle which lies anteriorly in the neck. It has two heads,
which originate from the fascia of the pectoralis major and deltoid. The fibres from the two heads
cross the clavicle, and meet in the midline, fusing with the muscles of the face. Superiorly, the
platysma inserts into the inferior border of the mandible. Innervation to the platysma is via the
cervical branch of the facial nerve.
The deep cervical fascia lies deep’ to the superficial fascia and platysma muscle. This fascia is
organised into several layers. These layers act like a shirt collar, supporting the structures and
vessels of the neck. Three layers of deep cervical fascia form the boundaries of the deep spaces in
the neck :
Superficial layer: investing fascia of the sternocleidomastoid and trapezius muscles, fascia of the
muscles of mastication, fascia between the hyoid and mandible that forms the floor of the
submandibular space, at least some of the fascia covering the parotid gland
Middle layer: strap muscle fascia, visceral fascia that encloses the thyroid gland and aerodigestive
tract (pharynx, larynx, trachea, esophagus)
Deep layer: perivertebral fascia of the prevertebral and paraspinal muscles, alar fascia
All three layers contribute to the carotid sheath.
Investing Layer, The
investing layer is the most
superficial of the deep
cervical fascia. It
surrounds all the structures
in the neck. Where it
meets the trapezius and
sternocleidomastoid
muscles, it splits into two,
completely surrounding
them. The investing fascia
can be thought of as a
tube; with superior,
inferior, anterior and
posterior attachments:
Superior – attaches to the
external occipital
protuberance and the
superior nuchal line of the
skull. Anteriorly – attaches
to the hyoid bone.
Inferiorly – attaches to the spine and acromion of the scapula, the clavicle, and the manubrium of
the sternum. Posterior – attaches along the nuchal ligament of the vertebral column
The pretracheal layer of fascia is situated in the anterior neck. It spans between the hyoid bone
superiorly and the thorax inferiorly (where it fuses with the pericardium). The trachea, oesophagus,
thyroid gland and infrahyoid muscles are enclosed by the pretracheal fascia. Anatomically, it can
be divided into two parts: Muscular part – encloses the infrahyoid muscles. Visceral part – encloses
the thyroid gland, trachea and oesophagus. The posterior aspect of the visceral fascia is formed by
contributions from the buccopharyngeal fascia (a fascial covering of the pharynx).

Thyroid
gland

Esophagus

The prevertebral fascia surrounds the vertebral column and its associated muscles; scalene muscles,
prevertebral muscles, and the deep muscles of the back. It has attachments along the antero-
posterior and supero-inferior axes:
Superior attachment – base of the skull.
Anterior attachment – transverse processes and vertebral bodies of the vertebral column.
Posterior attachment – along the nuchal ligament of the vertebral column
Inferior attachment – fusion with the endothoracic fascia of the ribcage. (The ligamentum nuchae is
a large median ligament composed of tendons and fascia located between the posterior muscles of
the neck. It covers the spines of C1 to C6 vertebrae. It is a superior and posterior extension of the
supraspinous ligament.)
The anterolateral portion of prevertebral fascia forms the floor of the posterior triangle of the neck.
It also surrounds the brachial plexus as it leaves the neck and subclavian artery as it passes through
the lower neck region – in doing so, it forms the axillary sheath.
The carotid sheaths are paired structures on either side of the neck, which enclose an important
neurovascular bundle of the neck. The contents of the carotid sheath are: Common carotid artery,
Internal jugular vein. Vagus nerve. Accompanying cervical lymph nodes.
The fascia of the carotid sheath is formed by contributions from the pretracheal, prevertebral, and
investing fascia layers. The carotid artery bifurcates within the sheath into the external and internal
carotid arteries. The carotid fascia is organised into a column, which runs between the base of the
skull to the thoracic mediastinum. This is of clinical importance as a pathway for the spread of
infection.