Differential Diagnosis Their Space of Origin.
H. Ric Harnsberger1 and Anne G. Osborn

of Head and Neck 1. The Suprahyoid

Lesions Based on Part of the Neck










portion of the head and neck, focusing on the normal spatial anatomy as defined by the deep cervical fascia, the appearance of a generic mass in each of the spaces defined, and the unique differential diagnoses involved in each individual space.

The cylindrical soft-tissue core of the extracranial of the head and neck, excluding the more anterior

portion parts of

and infrahyoid portions. The three layers of deep cervical fascia that cleave this area of the body into functional spaces converge on the hyoid bone, dividing the neck into these two parts (Fig. 1) [i , 2]. The suprahyoid area encompasses the deep spaces between the skull base and hyoid bone, and the infrahyoid portion lies inferiorly between the hyoid bone and the clavicles.

the orbit, sinonasal region, and oral cavity, can be subdivided at the hyoid bone into two distinct regions: the suprahyoid

In the suprahyoid area, the three layers of deep cervical fascia delineate the individual spaces of the deep part of the
face (Figs. i -4). As the contents of these spaces are some-

Fig. 1.-A and B, Axial drawing (A) and corresponding MR image (B) of normal anatomy of mid nasopharynx. Left side of drawing shows critical normal anatomy of region. Right side shows three layers of deep cervical fascia and spaces they define. See key on page 148. (Reprinted with permission from Harnsberger [2].)


December 1 7, 1990. Center, 50 N. Medical Dr., Salt Lake City, UT 841 32. Address

October authors:

1 5, 1 990; accepted Department

after revision University


of Radiology,

of Utah Medical

reprint requests to H. A.

Harnsberger. AJR 157:147-154, July 1991 0361-803x/91/1571-0147 © American Roentgen Ray Society

minor salivary glands. 5-8) [2. A retropharyngeal space lesion displaces the prevertebral mus- space. masticator (Fig. The parapharyngeal space is an area of fatty areolar tissue lymphoid tissues of Waldeyer ring. and carotid (Fig.i 48 HARNSBERGER AND OSBORN AJR:157. 6). 4]. and levator palatini muscles. It is delimited by the middle layer of deep fascia (Fig. displacing it laterally (Fig. The pharyngeal ryngeal cervical mucosal space is medial to the parapha- (Fig.4]. This method is particularly effective in lesions involving the four spaces surrounding the parapharyngeal space: the pharyngeal mucosal the deep face (Figs. branches of the trigemmnal nerve. cartilaginous eustachian tube. differential diagnostic possibilities can be sug- with complex fascial margins that lies in a central location in gested when a lesion is identified within a given space (Table 1). Lesions involving the two midline spaces. are best evaluated by noting the relationship of the lesion to the prevertebral muscles. 5A) [2. In order to definitely ascribe a lesion as primary to the parapharyngeal space. 1-3). and the pterygoid venous plexus. 7). pharyngobasilar fascia. 5). containing only fat. It extends from the skull base to the hyoid bone. 8) spaces. Its major contents include the mucosa. Anterior to the parapharyngeal space is the masticator . 5). des posteriorly (Fig. fat must be identified surrounding the whole circumference of the lesion [5]. superior and middle constrictor muscles. parotid (Fig. 9). A mass in the pharyngeal mucosal space is centered medial to the parapharyngeal space. the retropharyngeal and prevertebral spaces. A simple method of assigning a suprahyoid lesion to a specific space of origin is accomplished by establishing the center of the lesion and assessing its displacement of the parapharyngeal space fat (Figs. whereas a prevertebral space lesion displaces the muscles anteriorly (Fig. i 0) [4]. July 1991 Key to Abbreviations and Symbols Used in Figures i 5 6 buccinator muscle 7 hyoglossus muscle intrinsic muscles of tongue lateral pterygoid muscle 49 50 Si 53 soft palate uvula hyoid bone ramus of the mandible mandibular canal styloid process temporalis muscle 8 9 i0 masseter muscle medial pterygoid muscle mylohyoid muscle 54 57 58 59 ii i2 13 14 15 palatoglossus muscle (anterior tonsillar pillar) palatopharyngeus muscle (posterior tonsillar pillar) paraspinal platysma muscles muscle tensor veli palatini muscle levator veli palatini muscle 60 61 62 63 a 65 spinal accessory torus tubarius lateral pharyngeal artery buccal space carotid space danger space nerve recess (fossa of Rosenm#{252}ller) prevertebral styloglossus muscles muscle muscle 16 17 18 19 20 21 22 23 24 superior pharyngeal trapezius muscle constrictor muscle of V3) CS DS m MS inferior alveolar nerve (branch lingual nerve (branch of V3) facial nerve (VII) n muscle masticator node space 25 26 glossopharyngeal nerve (IX) vagus nerve (X) hypoglossal nerve (XII) sympathetic plexus 30 31 32 external internal carotid carotid artery artery internal lingual jugular maxillary artery vein artery PCS PMS PPS PS PVS RPS SLS SMS TS posterior cervical space pharyngeal mucosal space parapharyngeal space parotid space prevertebral space retropharyngeal space 33 34 sublingual space submandibular space temporal space (suprazygomatic masticator facial vein v space) vein 35 36 37 40 41 pharyngeal venous plexus retromandibular vein adenoids faucial tonsil heavy black line outlines pharyngobasilar superficial fascia layer of cervical _____medium ------ black line outlines deep cervical fascia middle layer of deep 43 45 46 48 parotid gland submandibular gland submandibular gland duct cartilaginous eustachian tube dotted line outlines fascia broken line outlines fascia deep layer of deep cervical what unique.

empties into masticator space. C = carotid canal. Coronal part of neck. 6A). Associated widening of the stylomandibular notch (Fig. A mass is said to originate from the masticator space when its center is anterior to the parapharyngeal space. 3. by the superficial layer of deep cervical fascia (Fig. Principal components tion. key on page 148. Important contents include the parotid gland. 7A) is usually seen. A mass is described the parapharyngeal as originating the parotid in the parotid cator space malignancy may spread permneurally nerve into along the the space and displaces the parapharyngeal mandibular division of the trigeminal cranial fossa (Fig. 6C). See key on page 148. See Fig. (Reprinted with permission from Harnsberger [2]. Axial drawing (A) and corresponding MR image (B) of normal anatomy of mid oropharynx. The superior margin of the parotid space abuts the external auditory canal. Carotid space receives cranial masticator spaces. The superficial layer of deep cervical fascia splits to envelop this space. 4.) with permission from space. external within carotid gland artery. 0 / A Fig. See key on page 148. intraparotid It too is circumscribed facial nerve. FS = foramen spinosum. Foramen ovale (FO). Parotid space .-Axialdrawing of skull base shows relationship of spaces of suprahyoid part of neck to skull base apertures.) B .-A and B. Critical contents of spaces are on left three layers of deep cervical fascia are on right. 2. displacing the fat from anterior to posterior (Fig.. Masti- include the muscles body of the mandible. FL = foramen lacerum. middle fat from lateral to medial. of mastica- Lateral to the parapharyngeal space is the parotid space. 3A) and extends mnferiorly to the inferior margin of the mandible. through which passes mandibular division of trigeminal nerve. July 1991 SITES OF SUPRAHYOID LESIONS 149 Fig.-A of suprahyoid and B. 7A). space when retromandibular it is centered vein. It has a suprazygomatic component (Fig. and inferior alveolar vein and artery. B drawing (A) with corresponding MR image (B) of normal anatomy of spaces Note craniocaudal extent of these spaces. whereas stylomastold foremen (SF) transmits facial nerve directly into parotid space. (Reprinted with permission from Hamsber- ger [2].) nerves lX-Xl from jugular foramen (J) and cranial nerve XII from hypoglossal canal (HC). especially parapharyngeal and Critical contents of spaces on left three layers of deep cervical fascia on right.AJR:157. lateral and to lymph nodes. whereas the parotid tail often extends mnferiorly below the inferior mandibular margin. (Reprinted Osborn et al [3]. ramus and posterior masticator and inferior alveolar nerves.

melanoma. direct invasion from primary squamous cell carcinoma Prevertebral Pseudomass Vascular Inflammatory Benign tumor Vertebral Vertebral Vertebral body osteophyte/anterior disk herniation artery aneurysm. internal carotid artery mural thrombus. metastases mi- Miscellaneous Masticator Pseudomass Congenital Inflammatory Benign tumor Malignancy Thornwaldt cyst hypertrophy. malignant mixed tumor. breast or non-Hodgkin lymphoma Ectatic common internal jugular or internal carotid artery. hemangioma/lymphangioma Abscess/cellulitis/reactive adenopathy. non-Hodgkin lymphoma. other: acinar cell carcinoma. (mandibular Benign masseteric denervation accessory division parotid gland. internal carotid artery dissection Paraganglioma. neurofibroma (brachial plexus). mandibular osteomyelitis Leiomyoma. lipoma. cyst abscess. mandibular metastases. metastases direct invanon-Hodg- Retropharyngeal Pseudomass Congenital inflammatory Benign tumor Malignancy Tortuous carotid artery. neu- Benign tumor Malignancy rofibroma) Squamous cell carcinoma nodal metastasis. lipoma Mucoepidermoid carcinoma. squamous cell carcinoma from oropharynx Parotid Congenital Inflammatory Benign tumor Malignancy First branchial cleft cyst. ectasia body osteomyelitis Malignancy Chordoma. chondrosarcoma. or radiation) mucosal inflammation Tonsil hypertrophy. aneurysm. non-Hodgkin lymphoma. malignant schwannoma. tu- non-Hodgkin lymphoma. nor salivary gland malignancy. thyroid carcinoma. Malignancy Pharyngeal mucosal nerve sheath tumors Malignant tumor of salivary gland rest. cystic Warthin carcinoma.150 HARNSBERGER AND OSBORN AJA:157. edema secondary to deep ye- nous obstruction Hemangioma Reactive adenopathy/cellulitis/abscess Lipoma Nodal metastases from squamous cell carcinoma. V) atrophy Hemangioma/lymphangioma Odontogenic abscess. non-Hodgkin lymphoma. tonsillitis. vertebral body primary malignant tumor . vertebral body benign bony tumors Vertebral body/epidural metastasis. direct spread of tumor from adjacent spaces Pseudomass Inflammatory Benign tumor Malignancy Asymmetric (pharyngitis calcification fossa of RosenmUller. adenocarcinoma. July 1991 TABLE 1: Differential Diagnosis Space/Type of Deep Facial Lesions Based on Their Space of Origin of Abnormality Parapharyngeal Pseudomass Congenital inflammatory P ssible 0 D agnosis Asymmetric Second Infection pterygoid from venous plexus atypical spaces adjacent branchial spreading cleft cyst. cell carcinoma nodal or melanoma. autoimmune/SjOgren syndrome Benign mixed tumor (pleomorphic mor. osteosarcoma). pseudoaneurysm. adenoid adenoma). nerve sheath tumor Sarcoma (soft tissue. sion by primary squamous cell carcinoma. kin lymphoma. asymmetric vein Carotid space cellulitis or abscess Jugular vein thrombosis or thrombophlebitis. nerve sheath tumor (schwannoma. postinflammatory or retention Benign mixed tumor of minor salivary gland origin Squamous cell carcinoma. squamous cell carcinoma Metastases Carotid Pseudomass Inflammatory Vascular Skin squamous lung carcinoma. Benign tumor Pleomorphic adenoma of salivary gland rest. schwannoma. benign lymphoepithelial cysts (AIDS). non-Hodgkin lymphoma.

6. A . See key on page 148. (Reprinted with permission from Harnsberger [4]. m = muscle. A B A B Fig.) B. invading parapharyngeal space from medial to lateral. Axial Ti-weighted unenhanced MR image of masticator space chondrosarcoma (C). Superficial layer of deep cervical fascia surrounds muscles of mastication and mandible. Center of masticator space mass (black dot) is anterior to posteriorly displaced parapharyngeal space (black area). cranial nerves IX-Xll. 8A).AJR:157. Posterior to the parapharyngeal space is the carotid space. and deep cervical lymph node chain. Middlelayer of deep cervicalfascia (dotted line) encompasses posterolateral margin of superior constrictor muscle. C. dofining pharyngeal mucosal space. 7C). All three layers of deep cervical fascia contribute to the carotid extends from the skull base to the aortic arch. Center of pharyngeal mucosal space mass (black dot) is medial to laterally displaced parapharyngeal space (black area). Coronal MR image of masticator space malignant schwannoma (5) with perineural tumor spread along mandibular division of trigemmel nerve (arrows) to skull base and through foramen ovale. July 1991 SITES OF SUPRAHYOID LESIONS 1S1 Fig. 5. Tumor involves muscles of mastication and mandible. Axial drawing through low nasopharynx shows contents and fascial boundaries of masticator space on left and appearance of masticator space mass (MS) on right.-A.) B. p = parapharyngeal mucosal space. invading parapharyngeal space from anterior to posterior. This space (Fig. Axial drawing through low nasopharynx shows contents and fascial boundaries of pharyngeal mucosal space (PMS) on left and pharyngeal mucosal space mass on right. Its suprahyoid contents include the internal carotid artery. (Reprinted with permission from Harnsberger [4]. Axial density-weighted MR image in patient with early nasopharyngeal carcinoma (N) in lateral pharyngeal re- cess of nasopharyngeal space.-A. p = parapharyngeal space. defining masticator space. jugular vein. C malignancy may follow the facial nerve into the temporal bone sheath that circumscribes this space (Fig.

Ti-weighted axial MR image in a patient with a large benign mixed tumor (BMT) of parotid space that widens stylomandibular notch (dotted llne) and impinges on fatty parapharyngeal space from lateral to medial (open arrow). Mucoepidermoid carcinoma of parotid space with penneural tumor following mastoid segment of facial nerve. Glomus vagale paraganglioma of nasopharyngeal carotid space. Center of mass (black dot) is lateral to medially displaced parapharyngeal space (black area). Note lack of identifiable fat plane between remaining normal parotid gland and mass (solid arrows). Coronal Ti-weighted MR image shows an intraparotid tumor (T) with a long “tail” extending to posterior genu of facial nerve canal within adjacent temporal bone along mastoid segment of facial nerve (arrows). Axial drawing through low nasopharynx shows contents and fascial boundaries of parotid space on left and appearance of a parotid space mass (PS) on right.) B. 7. C.-A. invading parapharyngeal space from lateral to medial. 8. defining carotid space. Plethora of serpiginous vascular flow voids within tumor signals its vascular nature and probable histology. v = vein.) B. (Reprinted with permission from Harnsberger [4]. a = artery. Superficial layer of deep cervical fascia surrounds parotid gland and its contents. Axial drawing through low nasopharynx shows contents and fascial boundaries of carotid space on left and appearance of a carotid space mass (CS) on right. See key on page 148. defining parotid space. Center of mass (blackdot) is posteriorto anteriorly dis- placed parapharyngeal space (black area). July 1991 A B Fig. A B .-A. (Reprinted with permission from Harnsberger [4]. invading it from posterior to anterior. which circumscribes carotid artery. jugular vein. j = internal jugular vein. Axial TI-weighted MR image of a right carotid space paraganglioma (PG) shows anterior displacement of parapharyngoal space fat (P). Right internal carotid artory is thrombosed. All three layers of deep cervical fascia contribute to ca- rotid sheath.152 HARNSBERGER AND OSBORN AJR:157. C Fig. and associated cranial nerve and lymph nodes.

through [4]. Note somewhat “bow tie” shape of retropharyngeal space mass. Axial drawing at level of low oropharynx shows a mass lesion originating within prevertebral space (PVS) proper with anterior displacement of prevertebral muscles (arrows). especially ca- A B rotid artery. retropharyngeal space (RPS). (Reprinted with permission from Harnsberger D. Key differential feature is direction of displacement of carotid space contents. B. Pharyngeal mucosal space (broken line) is displaced anteriorly. See key on page 148. and provertebral muscle (white p) posteriorly. whereas prevertebral muscles (p) are flattened along their anterior surface.) B. Axial Ti-weighted MR im- age shows clival colonic metastatic deposit (CM) extending into adjacent prevertebral space (asterisks). (Reprinted with permission from Harnsberger [4]. which has its center (black dot) posteromedial to parapharyngeal space (black area) and displaces it anterolaterally (compare with Fig. and pha- ryngeal mucosal space (PMS). Colonic metastasis to lower clivus with extension into adjacent prevertebral space. Squamous cell carcinoma of postenor wall of oropharynx invading adjacent retropharyngeal space. 8A). internal carotid artery is displaced laterally.-A.AJR:i57. 9. vertebral body is partially destroyed by lesion. C D Fig. Prevertebral muscles (m) are displaced anteriorly. See key on page 148. A B . As is commonly the case in infection and malignancy of the prevertebral space. Axial drawing of extra- nodal mass lesion of retropharyngeal space (RPS) at level of oropharynx causing posterior displacement of prevertebral muscles (arrows) within prevertebral space proper (PVS) and anterior displacement of pharyngeal mucosal space (PMS). Malignant squamous of retropharyngeal weighted MR image space. Axial drawing through low naso- pharynx shows appearance of nodal mass lesion of retropharyngeal space (RPS).) cell carciDensitylow naso- noma node within lateral nodal chain pharynx reveals a lateral retropharyngoal space malignant node (N) that displaces internal carotid artery (c) posterolaterally. (Reprinted with permission from Harnsberger [4]. parapharyngeal space fat (black p) anterolaterally.July 1991 SITES OF SUPRAHYOID LESIONS 153 Fig. Enhanced axial CT scan shows tumor (T) within oropharyngeal retropharyngeal space. Carotid space masses can be confused with lateral retropharyngeal space lesions unless there is awareness of their unique characteristics. 10. C.-A. In lateral retropharyngeal space masses.

When the mass lymph nodes and the retropharyngeal space diffusely. Holyoke E. CT and MRI of masses of the deep face. A lesion riorly (Fig. This space vertebral body. are seen to be displaced posteriorly occurs in the laterally placed nodes.7:91-106 4. Smoker WAK. The supra- the prevertebral (Fig. 9C and 9D). 1 OA). Hamsberger The prevertebral space proper is defined by the deep layer of deep cervical fascia as it passes superficial to the prevertebral muscles to attach to the cervical transverse processes 1988:169:81-85 . Sacher M.63:367-407 of the head and fat. the cord. Harnsberger HA. Common diagnosis. 9A). Lawson of the parapharyngeal space: refined imaging W. July 1991 mass lesion is primary to the carotid space when it is centered posterior to the parapharyngeal space and displaces it ante- (Fig. 1 OB). and the spinal muscles. Head and neck radiology volume. Base of skull imaging. Semin Ultrasound CTMR i986. Osborn AG. Som PM. The fascia and fascial spaces neck and adjacent regions. REFERENCES 1 . St. It extends from the skull hyoid base to the level of the T3 vertebral retropharyngeal space contains only body. contains the prevertebral and vein. Grodlinsky M. tumors Radiology 2. Louis: Mosby-Year Book Medical. Biller HF. it will impinge on the parapharyngeal (Figs. originates places from the prevertebral muscles space anteriorly proper when it dis- The retropharyngeal space is a posterior midline space that has the middle layer of deep cervical fascia as its anterior margin and the deep layer of deep cervical fascia as its posterior and lateral margins (Fig. 9B). artery.i6:147-173 3. Am J Anat 1938. Harnsberger HR. Stollman AL.154 HARNSBERGER AND OSBORN AJR:i57. Curr Probl Diagn Radiol i987. 1990 5. Handbooks in radiology. space posteromedially HR. 8B). When disease affects the prevertebral muscles (Fig.