This article presents a comprehensive analysis of the neck fascia and neck spaces that are formed by the interplay of the different fascial layers. Because a solid and thorough understanding of the anatomy and relationship of the various neck spaces is so valuable in diagnosing and treating diseases of the neck, this information organizes the anatomic areas of the neck beginning with and overview, followed by extent, anatomic relationship, and contents. Detailed enhanced computed tomography images display the anatomic areas of the neck.
Key Points
- •
There are many opinions about what defines the neck spaces and how to best organize them into useful clinical tools.
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A solid understanding of the anatomy and relationship of the various neck spaces is valuable in diagnosing and treating diseases of the neck.
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The neck has 2 layers of fascia, the superficial and deep layers.
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The superficial cervical fascia is a thin layer that consists mainly of loose areolar connective tissue and adipose tissue that extends from the head to the thorax and the shoulders to the axilla.
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The deep cervical fascia, or fascia colli, is subdivided into 3 layers:
- 1.
Superficial layer of deep cervical fascia
- 2.
Middle layer of deep cervical fascia
- 3.
Deep layer of deep cervical fascia
- 1.
Fascia of the neck
The anatomy of the neck is complex and, as a result, not very well understood. There are many opinions about what defines the neck spaces and how to best organize them into useful clinical tools. This article presents a comprehensive analysis of the neck fascia and neck spaces that are formed by the interplay of the different fascial layers. A solid understanding of the anatomy and relationship of the various neck spaces is valuable in diagnosing and treating diseases of the neck ( Table 1 ).
| ACS | Anterior cervical space |
| AMS | Aerodigestive mucosal space |
| CS | Carotid space |
| DS | Danger space |
| DDCF | Deep layer of deep cervical fascia |
| IHN | Infrahyoid neck |
| MDCF | Middle layer of deep cervical fascia |
| MS | Masticator space |
| PCS | Posterior cervical space |
| PMS | Pharyngeal mucosal space |
| PPS | Parapharyngeal space |
| PS | Parotid space |
| PTS | Peritonsillar space |
| PVS | Perivertebral space |
| RPS | Retropharyngeal space |
| SCF | Superficial cervical fascia |
| SDCF | Superficial layer of deep cervical fascia |
| SHN | Suprahyoid neck |
| SLS | Sublingual space |
| SMS | Submandibular space |
| SQCCA | Squamous cell carcinoma |
| VS | Visceral space |
| Space | Congenital | Inflammatory | Benign Neoplasm | Malignant Neoplasm | Other |
|---|---|---|---|---|---|
| Masticator | Fibrous dysplasia | Odontogenic abscess | Schwannoma | AMS SQCCA, sarcoma | |
| Parapharyngeal space | Branchial cleft cyst | Pharyngitis spread | Pleomorphic adenoma | AMS SQCCA, adenoid cystic carcinoma | |
| Parotid | Branchial cleft cyst | Sialadenitis, HIV cysts | Pleomorphic adenoma | Mucoepidermoid carcinoma | Cranial nerve VII schwannoma |
| Carotid space | Branchial cleft cyst | Thrombophlebitis | Schwannoma, paraganglioma | Lymphadenopathy | Carotid dissection, pseudoaneurysm |
| Retropharyngeal space | Medial carotid deviation | Adenitis, abscess | Lipoma, hemangioma | AMS SQCCA, Nodes | |
| Perivertebral space | Lymphangioma | Discitis, osteomyelitis | Schwannoma, chordoma | Metastases to bones, lymph nodes | Sarcomas |
The neck has 2 layers of fascia, the superficial and deep layers. The superficial cervical fascia is a thin layer that consists mainly of loose areolar connective tissue and adipose tissue that extends from the head to the thorax and the shoulders to the axilla. It lies between the dermis of the skin and the deep cervical fascia and contains the platysma, muscles of facial expression, cutaneous nerves, blood vessels, and lymphatics.
The deep cervical fascia, or fascia colli, is subdivided into 3 layers ( Fig.1 ) : (1) superficial layer of deep cervical fascia , (2) middle layer of deep cervical fascia , and (3) deep layer of deep cervical fascia .
The superficial layer of deep cervical fascia lies between the superficial cervical fascia and the muscles of the neck. It attaches anteriorly to the hyoid bone and superiorly to the lower border of the mandible, the mastoid process, the superior nuchal line, and the external occipital protuberance, to invest all the superficial neck structures. It splits to encircle the sternocleidomastoid and trapezius muscles to blend posteriorly with the ligamentum nuchae and splits again between the angle of the mandible and the mastoid process to enclose the parotid gland. Inferiorly, it attaches to the spine and acromion of the scapula, the clavicle, and the manubrium.
The middle layer of deep cervical fascia extends from the skull base superiorly to the mediastinum inferiorly and anteriorly from the hyoid bone to the thoracic inlet. It is divided into the muscular division and visceral divisions. The muscular division surrounds the strap muscles, the sternohyoid, sternothyroid, omohyoid, and thyrohyoid and forms a pulley through which the intermediate tendon of the digastrics muscles passes to suspend the hyoid bone. Over the sternocleidomastoid, it fuses with the superficial layer of deep cervical fascia. The visceral division, which is also called the buccopharyngeal in the suprahyoid neck, encloses the visceral structures of the neck: the pharynx, larynx, esophagus, trachea, thyroid, and parathyroid glands; periesophageal lymph nodes; and the recurrent laryngeal nerve. This layer attaches posteriorly to the prevertebral fascia and blends with the investing fascia at the lateral borders of the infrahyoid muscles.
The deep layer of deep cervical fascia surrounds the deep muscles of the neck and the cervical vertebrae. Extending from the skull base into the mediastinum, the deep cervical fascia has 2 distinct divisions: the alar and prevertebral layers. The alar layer forms the posterior and lateral walls of the retropharyngeal space and bridges the transverse processes of the vertebrae. The prevertebral layer encloses the paraspinal muscles: the longus colli and longus capitis muscles; the anterior, middle, and posterior scalene muscles; and the levator scapulae. The prevertebral fascia also surrounds the brachial plexus trunks, phrenic nerve, cervical plexus, vertebral artery, and vertebral vein, with the cervical sympathetic trunk fixed into the anterior part of the fascia.
Neck spaces
The suprahyoid neck spaces comprise the area from the base of the skull to the hyoid bone excluding the orbits, paranasal sinuses, and the oral cavity. In the suprahyoid region, the spaces of the neck include the sublingual space, submandibular space, peritonsillar space (PTS), parapharyngeal space, pharyngeal mucosal space, masticator space, parotid space, carotid space ( Fig. 2 ), retropharyngeal space, danger space (DS), and perivertebral space.
In the infrahyoid neck, the visceral space is present, whereas the masticator space, parapharyngeal space, and parotid space are no longer present. The carotid space, retropharyngeal space, DS, and the perivertebral space span the suprahyoid and infrahyoid compartments.
The suprahyoid neck
Sublingual Space
Overview
The sublingual space is a potential space that lies entirely within the oral cavity and, as such, has no fascial margins. It is a paired space, but the 2 sides communicate anteriorly through an isthmus under the frenulum of the tongue.
Extent
The sublingual space is a small space within the oral tongue that is bordered anteriorly by the mandible, inferolaterally by the mylohyoid muscle, and medially by the genioglossus and geniohyoid muscles ( Fig. 3 ).
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