Pariyanan Jaruchinda

Department Of Otolaryngology
Phramongkutklao Hospital
Anatomy of cervical fascia

Cervical fascia

1) Superficial cervical fascia

2) Deep cervical fascia

 Superficial Cervical Fascia

• Encircle H&N and attached to clavicle and

zygomatic arch
• Contain plastysma m. and external jugular v.
• Marginal mandibular br. of facial n. lies just
deep to superficial cervical fascia
 Deep Cervical Fascial

1) Superficial layer

2) Middle layer

3) Deep layer
 Superficial layer
(Enveloping,Investing,Anterior layer)
• From ligamentum nuchae,
completely enclose the neck
• Encircle trapezius m. ,
sternocleidomastiod m.
• Encircle submandibular gl.,
parotid gl.,masticater muscle
• Create superficial sternal
space (of Burn)
 Middle layer
(Cervical layer,Pretracheal layer)
• Encircle strap m.
(muscular division)
• Encircle esophagus
trachea,thyroid gl.,
pharynx (visceral
division)
• Buccopharyngeal fascia
( part of visceral
division that cover
constrictor m. and
buccinator m.)
 Deep layer
(Carpet fascia)
• Cover vertebral body
and paraspinous m.
• Devided into
1. Alar division
from base of skull to T2
level
2.Prevertebral division
from base of skull to
diaphram
 Carotid sheath
• Extend from skull base to
clavicle
• Made up of 3 layer of deep
cervical fascia
• Contain carotid a., internal
jugular v., vagus n. and
sympathetic chain
• Avenues for spread of
infection from neck to
mediastinum
 Deep Neck Space Anatomy

• Space Involving Entire Length Of Neck

• Space Limited To Above The Hyoid Bone

• Space limited To Below The Hyoid Bone

 Space Involving Entire Length Of
Neck

1. Retropharyngeal Space
2. Danger Space
(Prevertebral Space)
3. Paravertebral Space
4. Carotid Sheath Space
 Retropharyngeal Space
• Between visceral
division of middle layer
and alar division of deep
layer
• Extend from skull base
to T2 level
• Midline raphae
• More commom in
children due to presence
of retropharyngeal node
 Danger Space
• Between alar division and
prevetebral division of
deep layer (locate
posterior to
retropharyngeal space)
• Extend from skull base to
diaphram
• No midline raphae
• Infection spread from
neck to posterior
mediastinum easily
 Paravertebral Space
• Between prevertebral
division of deep layer and
vertebral bodies
• Extend from skull base to
coccyx
• Infection in this space is
rare and spread slowly due
to compact connective
tissue
 Carotid sheath Space
• Made up from all
deep cervical fascia
• Infection from any
deep fascia can
spread to this space
(lincoln High way)
 Space Limit To Above The Hyoid Bone

1. Parapharyngeal Space
2. Submandibular Space
3. Masticator Space
4. Temporal Space
5. Parotid Space
 Parapharyngeal Space
(Lateral phryngeal Space)
(Pharyngomaxillaly Space)
Boundary

• Superiorly : Skull base

• Inferiorly : Hyoid bone
• Laterally : Medial pterygoid m.
• Medially :Buccopharyngeal fascia
• Anteriorly : Submandibular space
• Posteromedialy : Prevertebral fascia
and retrophryngeal space
 Submandibular Space

Divided into 2 spaces by

mylohyoid m.
1. Sublingual space (above
mylohyoid m.)
2. Submaxillaly space (below
mylohyiod m.)

• These 2 spaces can

communicate each other
by mylohyoid cleft
 Masticator Space
• Between masticator m.
and superficial layer of
deep cervical fascia
(Masticator m. = massestor
m.,medial and lateral
pterygoid m. and
temporalis muscle)
• Locate anterior and
lateral to parapharyngeal
space
 Parotid Space
• Between parotid gl. and
superficial layer of deep
cervical fascia
• Infection can spread
easily to parapharyngeal
space due to incompleted
encircle at upper inner
surface of parotid gl.
Space Limit To Below The Hyoid Bone
Anterior Viseral Space
(Pretracheal Space)
• Between trachea,
esophagus and middle
layer of deep cervical
fascia
• Extend from hyoid bone
to superior mediastinum
 Etiology Of Deep neck Space
1. Dental infection
2. Tonsillar and peritonsillar
infection
3. Trauma of upper aerodigestive
tract
4. Retropharyngeal lymphadenitis
5. Pott’s disease
6. Sialadenitis
7. Bezold’s abscess
8. Infection of congenital cyst and
fistula
9. Intravenous drug abuse
SPECIFIC DEEP NECK
INFECTION
 PARAPHARYNGEAL SPACE
INFECTION
• Most common cause :
Peritonsillar infection
• Typical finding
1.Trismus
2. Angle mandible
swelling
3. Medial
displacement of lateral
pharyngeal wall

Others : fever, limit neck

motion,neurologic
deficit (C.N
9,10,12,Horner’s
syndrom)
 PARAPHARYNGEAL SPACE INFECTION

Treatment
1. Evaluate and maintain airway & fluid hydration
2. Parenteral antibiotic high dose 24-48 hrs.
3. If not improve, consider surgical drainage
 PARAPHARYNGEAL SPACE INFECTION

Surgical drainage
1. Intraoral approch
(for peritonillar abscess only)
2. External approach
-transverse submandibular
incision
-T. shape incision (Mosher)
 SUBMANDIBULAR SPACE
INFECTION
Most common cause :
Dental caries
• Anterior teeth & first molar
: infection enter sublingual
space
• Second & third molar
: infection enter
submaxillary space
 SUBMANDIBULAR SPACE INFECTION

• Organisms
- Mixed of aerobes(alpha hemolytic strep,
staph) and anaerobes make synnergistic effect
of endotoxins
- Consider gram – in immunocompromize host
 SUBMANDIBULAR SPACE INFECTION

Clinical feature
(True Lugwig’s angina)
• Start unilateral and progress
bilaterally
• Induration of submandibular
region and floor of mouth
( severe cellulitis)
• Tongue trusted posteriorly and
superiorly (cause airway
obstruction)
• Drolling, odynophagia, trismus,
fever
• No purulence(due to no time to
developed)
 SUBMANDIBULAR SPACE INFECTION
Treatment
• Early stage
(unilat,mild swelling and edema)
-IV antibiotic, extration of infected
tooth
• Advance stage
(bilateral swelling, dysphagia with
drolling)
-early airway intervention
-surgical drainage
(submandibular incision)
RETROPHARYNGEAL SPACE INFECTION
PREVERTEBRAL SPACE INFECTION
Most commmon cause
• In children
-retropharyngeal lymphadenitis from
nose,PNS,ET)
• In adult
-regional truma and endoscopic procedure
 RETROPHARYNGEAL SPACE INFECTION
PREVERTEBRAL SPACE INFECTION

Clinical feature
• In children
irritability,neck rigidity,
fever,drolling,muffle cry,
airway compromise
• In adult
fever, sore throat,
odynophagia, neck
tenderness, dysnea
 RETROPHARYNGEAL SPACE INFECTION
PREVERTEBRAL SPACE INFECTION

Clinical feature
• Retropharyngeal space abscess
form abscess lateral to midline
• Prevertebral space abscess
form abscess in midline
• Mediastinitis S&S
Dysnea,chest pain, tachycardia,
fever,wideded mediastinum
 RETROPHARYNGEAL SPACE INFECTION
PREVERTEBRAL SPACE INFECTION

Investigation
1. Lateral neck film
- C2 > 7 mm. both
children and adult
- C7 > 14 mm. in children
> 22 mm. in adult.
2. Chest film
- detection of mediastinitis
 RETROPHARYNGEAL SPACE INFECTION
PREVERTEBRAL SPACE INFECTION

Treatment
Surgical drainage
1. Intraoral drainage
-Lesion confined in
larynx esp.child
2. External drainage (Dean)
-Lesion beyond
pharyngeal level
-Airway compromise
-Involve other deep
neck spaces
 PARAVERTEBRAL SPACE
INFECTION
• Most common cause
Penetrating trauma
(F.B, endoscope)
TB spine
• Infection spread slowly
and more localize due to
compact CNT.
Clinical feature
-Same as others
posterior space abscess
-Vertebral osteomyelitis
and spinal instability
 MASTICATOR SPACE INFECTION
• Most common cause Dental
carices
Clinical feature
• Extream trismus with minimum
facial swelling
- Massesteric space
(lateral compartment) :
edema at ramus of mandible
- Ptrygomandibular space
(medial compartment):
edema at retromolar trigone
 MASTICATOR SPACE INFECTION

Treatment
1. Intraoral drainage (medial compartment)
- along inner margin of mandibular ramus
to the retromolar trigone
2. External approch (lateral compartment)
- submandibular incision
- preauricular incision or Gilles incision for
temporal space abscess
 PAROTID SPACE INFECTION
• Most common cause :
Bacterial retrograde from oral
cavity
Clinical feature
• high fever, weakness, mark
swelling and tenderness of
parotid gland,fluctuation,pus
at stensen’s duct
 PAROTID SPACE INFECTION
Treatment
• IV ATB
• Surgical drainage indicated for
-fluctuation
-medical failure after 24-48 hr. or progression
of disease
 COMPICATION OF DEEP NECK INFECTION

1. Internal jugular vein thrombosis

2. Cavernous sinus thrombosis
3. Neurologic deficit
4. Osteomyelitis of the mandible
5. Osteomyelitis of the spine
6. Mediastinitis
7. Pulmonary edema
8. Pericarditis
9. Aspiration
10. Sepsis