Kj Lee 10Th Ed - Chapter 23 - Neck Spaces And Fascial Planes

Front 1

What are the following boundaries of the anterior cervical triangle?

Superior:
Anterior:
Posterior:

Back 1

Superior: mandible
Anterior: midline
Posterior: SCM

Front 2

What are the subordinate triangles of the anterior cervical triangle?

Back 2

Submandibular (digastric) triangle
Submental (suprahyoid) triangle
Carotid traingle
Muscular triangle

Front 3

Anterior Cervical Triangle

What are the following borders of the submandibular triangle?

Superior:
Anterior:
Posterior:

Back 3

Superior: mandible
Anterior: anterior belly of digastric
Posterior: posterior belly of digastric

Front 4

Anterior Cervical Triangle

What are the following borders of the submental triangle?

Superior:
Inferior:
Lateral:

Back 4

Superior: symphysis of mandible
Inferior: hyoid bone
Lateral: anterior belly of digastric

Front 5

Anterior Cervical Triangle

What are the following borders of the carotid triangle?

Superior:
Anterior:
Posterior:

Back 5

Superior: posterior belly of digastric
Anterior: superior belly of omohyoid
Posterior: SCM

Front 6

Anterior Cervical Triangle

What are the following borders of the muscular triangle?

Superior:
Anterior:
Posterior:

Back 6

Superior: superior belly of omohyoid & hyoid bone
Anterior: midline
Posterior: SCM

Front 7

What are the following boundaries of the posterior cervical triangle?

Anterior:
Posterior:
Inferior:

Back 7

Anterior: SCM
Posterior: trapezius
Inferior: calvicle

Front 8

What are the subordinate triangles of the posterior cervical triangle?

Back 8

Occipital triangle
Subclavian triangle

Front 9

Posterior Cervical Triangle

What are the following borders of the occipital triangle?

Anterior:
Posterior:
Inferior:

Back 9

Anterior: SCM
Posterior: trapezius
Inferior: inferior belly of omohyoid m

Front 10

Posterior Cervical Triangle

What are the following borders of the subclavian triangle?

Superior:
Inferior:
Anterior:

Back 10

Superior: inferior belly of omohyoid
Inferior: clavicle
Anterior: SCM

Front 11

What are the four main fascial layers of the neck?

Back 11

Superficial cervical fascia

Superficial layer of deep cervical fascia (investing fascia)
Middle layer of deep cervical fascia (visceral fascia)
Deep layer of deep cervical fascia (prevertebral fascia)

Front 12

What does the superficial cervical fascia envelop?

Back 12

Platysma & muscles of fascial expressions

Front 13

What are the following boundaries of the superficial cervical fascia?

Superior:
Inferior:

Back 13

Superior: zygomatic process

Inferior: clavicle

Front 14

What are the roles of the superficial cervical fascia?

Back 14

1) Main plane of resistance to deep neck spread of cellulitis
2) Allows mobility of skin over deep neck structures
3) Easily separated when raising neck flaps from deep cervical fascia in subplatysmal potential space (adipose, sensory nerves, blood vessels)

Front 15

What does the superficial layer of deep cervical fascia envelop?

Back 15

AKA Investing layer

- Trapezius, SCM, strap muscles
- Submandibular and parotid glands ***
- Muscles of mastication: masseter, pterygoids, and temporalis

Front 16

What are the following boundaries of the superficial layer of deep cervical fascia?

Superior:
Inferior:
Anterior:
Posterior:

Back 16

AKA Investing layer

Superior: Mandible and zygoma
Inferior: clavicle, acromion, spine of scapula
Anterior: hyoid bone
Posterior: mastoid process, superior nuchal line of cervical vertebrae

Front 17

Which fascial layer forms the stylomandibular ligament posteriorly?

Back 17

superficial layer of deep cervical fascia

Front 18

What does the middle layer of deep cervical fascia envelop?

Back 18

AKA visceral fascia

Muscular division: strap muscles (sternohyoid, sternothyroid, thyrohyoid, and omohyoid)

Visceral division: pharynx, larynx, trachea, esophagus, thyroid, parathyroid, buccinators, constrictor muscles of pharynx

Front 19

What are the following boundaries of the middle layer of the deep cervical fascia?

Superior:
Inferior:

Back 19

Superior: base of skull

Inferior: mediastinum

Front 20

Which cervical fascial layer forms the buccopharyngeal fascia?

Back 20

The middle layer of deep cervical fascia

Front 21

Which cervical fascial layer forms the pretracheal fascia?

Back 21

The middle layer of deep cervical fascia

Front 22

What does the deep layer of deep cervical fascia envelop?

Back 22

AKA Prevertebral fascia

paraspinous muscles and cervical vertebrae

Front 23

What are the following boundaries of the middle layer of the deep cervical fascia?

Superior:
Inferior:

Back 23

Superior: base of skull

Inferior: chest

Front 24

What are the two layers of the deep layer of deep cervical fascia?

Back 24

Prevertebral layer - attaches to the transverese process laterally and covers the vertebral bodies, paraspinous, and scalene muscles. It extends from the base of skull to the coccyx.

Alar layer - lies between the prevertebral layer and the visceral layer of the middle fascia and covers the cervical sympathetic trunk. Extends from the base of skull to the mediastium.

Front 25

What are the anterior and posterior borders of the cervical danger space?

Back 25

Anterior: alar fascia/layer

Posterior: prevertebral layer

Front 26

Name the layers and spaces going posteriorly, starting with the buccopharyngea/fascial layer

Back 26

Buccopharyngea/fascial layer (of middle layer of deep cervical fascia) --> retropharyngeal space --> alar fascia (of deep layer of deep cervical fascia) --> danger space --> preverterbal layer (of deep layer of deep cervical fascia)

Front 27

The prevertebral layer extends how far inferiorly?

Back 27

from the base of the skull to the coccyx

Front 28

The alar layer/fascia extends how far inferiorly?

Back 28

extends from the base of skull to the mediastinum

Front 29

What are the following boundaries of carotid sheath?

Superior:
Inferior:

Back 29

Superior: base of skull

Inferior: thorax

Front 30

Which layers of the cervical fascia make up the carotid sheath?

Back 30

ALL THREE layers of the deep cervical fascia (superficial, middle and deep)

Front 31

What is "The Lincoln Highway of the Neck?"

Back 31

The carotid sheath, due to potential avenue for rapid spread of infection

Front 32

What are the following borders of the parapharyngeal space?

Superior:
Inferior:
Anterior:
Posterior:
Medial:
Lateral:

Back 32

Superior: base of skull (middle cranial fossa)
Inferior: hyoid bone
Anterior: pterygomandibular raphe
Posterior: prevertebral fascia
Medial: pharyngobasilar fascia (superiorly), superior constrictor
Lateral: deep lobe of parotid gland, mandible, and medial pterygoid

Front 33

What are the two main compartments of the parapharyngeal space?

Back 33

Prestyloid and Poststyloid compartments separated by the styloid process

Front 34

What are the contents of the prestyloid and poststyloid compartments of the parapharyngeal space?

Back 34

Prestyloid compartment
- Fat
- Lymph nodes
- Internal maxillary artery
- Inferior alveolar, lingual, and auriculotemporal nerves
- Medial and lateral pterygoid muscles
- Deep lobe parotid tissue

Poststyloid compartment
- Carotid artery
- IJ vein
- Sympathetic chain
- Cranial nerves 9, 10, 11, 12

Front 35

What are the following boundaries of the pterygopalatine (pterygomaxillary) fossa?

Superior:
Anterior:
Posterior:
Medial:
Lateral:

Back 35

Superior: sphenoid body, palatine bone (orbital process)
Anterior: posterior wall of maxillary antrum
Posterior: pterygoid process, greater wing of sphenoid
Medial: palatine bone, nasal mucoperiosteum
Lateral: temporalis muscle via pterygomaxillary fissure

Front 36

What are contents of the pterygopalatine (pterygomaxillary) fossa?

Back 36

Maxillary nerve (V2)
Sphenopalatine ganglion
Internal maxillary artery

Front 37

What are the following boundaries of the masticator space?

Lateral:
Medial:

Back 37

Lateral: fascia over masseter muscle (superficial layer of deep cervical fascia)

Medial: fascia medial to pterygoid muscles (superficial layer of deep cervical fascia)

Front 38

What are the contents of the masticator space?

Back 38

(Number 2 in the picture; parotid space is number 4, and parapharyngeal space is 1)

Masseter muscle
Lateral and medial pterygoid muscles
Ramus and posterior body of mandible
Temporalis muscle tendon
Inferior alveolar nerve (V3)
Internal maxillary artery

Front 39

What are the following boundaries of the temporal fossa?

Superior:
Inferior:
Lateral:
Medial:

Back 39

Superior: temporal lines on lateral surface of skull (attachment of temporalis muscle)
Inferior: zygomatic arch
Lateral: temporalis fascia
Medial: skull including pterion

Front 40

What are the following boundaries of the infratemporal fossa?

Medial:
Lateral:
Anterior:
Superior:

Back 40

Medial: lateral pterygoid plate with tensor and levator palatini muscles, superior constrictor
Lateral: mandibular ramus, coronoid process
Anterior: infratemporal surface of maxilla
Superior: infratemporal crest bone (sphenoid and temporal bones) medially, space deep to zygomatic arch laterally

Front 41

What are the contents of the infratemporal fossa?

Back 41

Medial and lateral pterygoid muscles
Insertion of temporalis on coronoid process
Internal maxillary artery and branches
Pterygoid venous plexus
V3 with otic ganglion and chorda tympani
Posterior superior branch of V3

Front 42

What are the following boundaries of the parotid space?

Medial:
Lateral:

Back 42

Medial: parapharyngeal space

Lateral: parotid fascia (superficial layer of deep cervical fascia)

Front 43

What are the contents of the parotid space?

Back 43

Parotid gland
Facial nerve
External carotid artery and branches
Posterior facial vein

Front 44

What are the following boundaries of the peritonsillar space?

Medial:
Lateral:

Back 44

Medial: palatine tonsil
Lateral: superior constrictor muscle

Front 45

What are the contents of the pertonsillar space?

Back 45

Loose connective tissue
Tonsillar branches of lingual, facial and ascending pharyngeal vessels

Front 46

What are the following boundaries of the submandibular (submaxillary) space?

Superior:
Inferior:
Anterior:
Posterior:
Medial:
Lateral:

Back 46

Superior: floor of mouth mucosa
Inferior: digastric muscle
Anterior: mylohyoid and anterior belly of digastric
Posterior: posterior belly of digastric and stylomandibular ligament
Medial: hyoglossus and mylohyoid
Lateral: skin, platysma, and mandible

Front 47

Which muscle divides the submandibular space into two compartments? What are these two compartments?

Back 47

The mylohyoid muscle (arrows) acts like a sling to divides the submandibular space into a sublingual (green; infections anterior to 2nd molar) and submaxillary (light blue; infections of 2nd and 3rd molars) compartments

Front 48

What are the contents of the sublingual space/compartment?

Back 48

Sublingual space/compartment (Supramylohyoid)
- sublingual gland
- Wharton's duct
- Lingual nerve ***

Front 49

What are the contents of the submaxillary space/compartment?

Back 49

Submaxillary (inframylohyoid) space/compartment:
- Submandibular gland
- Lymph nodes
- Hypoglossal nerve ***
- Facial vein & artery
- Marginal branch of facial nerve

Front 50

What are the following boundaries of the carotid space?

Anterior:
Posterior:
Medial:
Lateral:

Back 50

Anterior: SCM
Posterior: prevertebral space (deep layer of DCF)
Medial: visceral space (middle layer of DCF)
Lateral: SCM

Front 51

What are the contents of the carotid sheath?

Back 51

Common carotid artery
Internal jugular vein (IJV)
Vagus nerve
Ansa cervicalis

Front 52

What are the following boundaries of the visceral space?

Superior:
Inferior:
Anterior:
Posterior:
Lateral:

Back 52

Visceral space (middle layer of DCF)

Superior: hyoid bone
Inferior: mediastinum (T4 level/arch of aorta)
Anterior: superficial layer of DCF
Posterior: retropharyngeal space; prevertebral fascia
Lateral: parapharyngeal space; carotid fascia

Front 53

What are the contents of the visceral space?

Back 53

Pharynx
Larynx
Esophagus
Trachea
Thyroid gland

Front 54

What are the following boundaries of the retropharyngeal (retrovisceral) space?

Superior:
Inferior:
Anterior:
Posterior:
Medial:
Lateral:

Back 54

Superior: base of skull
Inferior: superior mediastinum; tracheal bifurcation (T4); middle layer of DCF fuses with alar layer of deep layer of DCF
Anterior: pharynx and esophagus (middle layer of DCF - buccopharyngeal fascia)
Posterior: alar fascia
Medial: midline raphe of superior constrictor muscle (results in unilateral abscess in this space)
Lateral: carotid sheath

Front 55

What are the contents of the retropharyngeal space?

Back 55

retropharyngeal lymph nodes (pediatric infections of sinuses or nasopharynx)
connective tissue

Front 56

What are the following boundaries of the danger space?

Superior:
Inferior:
Anterior:
Posterior:

Back 56

Superior: base of skull
Inferior: diaphragm
Anterior: alar fascia of deep layer of DCF
Posterior: prevertebral fascia of deep layer of DCF

Front 57

What are the contents of the danger space?

Back 57

loose areolar tissue (danger space named due to potential for rapid spread of infection through this space)

Front 58

What are the following boundaries of the prevertebral space?

Superior:
Inferior:
Anterior:
Posterior:
Lateral:

Back 58

Superior: base of skull
Inferior: coccyx
Anterior: prevertebral fascia (results in midline abscess in this space)
Posterior: vertebral bodies
Lateral: transverse process of vertebrae

Front 59

What are the contents of the prevertebral space?

Back 59

Dense alreolar tissue
Muscle - paraspinous, prevertebral, or scalene
Vertebral artery and vein
Brachial plexus and phrenic nerve

Front 60

What is the most common cause of deep neck space infections in adults? How about in kids?

Back 60

adults - dental infections

pediatric - acute pharyngitis of Waldeyer's ring

Front 61

Describe the pathway of spread of the following infections to the deep neck.

Acute tonsillitis

Back 61

Acute tonsillitis --> peritonsillar abscess --> parapharyngeal space --> retropharyngeal space (will lead to the carotid sheath) OR submandibular space (will lead to the visceral space)

Front 62

Describe the pathway of spread of the following infections to the deep neck.

Rhinosinusitis/upper pharyngitis

Back 62

Rhinosinusitis/upper pharyngitis --> retropharyngeal lymph node --> retropharyngeal space --> parapharyngeal space or carotid sheath

Front 63

Describe the pathway of spread of the following infections to the deep neck.

Upper jaw dental infection

Back 63

Upper jaw dental infection --> masticator space --> ptergymaxillary space --> parapharyngeal space OR infratemporal space

Front 64

Describe the pathway of spread of the following infections to the deep neck.

Lower jaw dental infection

Back 64

1st molar infections --> sublingual space --> submandibular space

2nd and 3rd molar infections --> submandibular space --> parapharyngeal or visceral spaces

Front 65

Describe the pathway of spread of the following infections to the deep neck.

Esophagoscopy/intubation/trauma

Back 65

Esophagoscopy/intubation/trauma --> parapharyngeal space or retropharyngeal space --> danger space and/or mediastinum

Front 66

A neck phlegmon/abscess is identified on a CT. What percentage of cases will yield no pus return on neck exploration?

Back 66

25%

Front 67

What is the main source of mortality from deep neck infections?

Back 67

loss of airway

Front 68

Airway is most at risk with infections of which cervical spaces?

Back 68

submandibular space
parapharyngeal space
retropharyngeal space

Front 69

What are the indications for acute "quinsy" tonsillectomy?

Back 69

1) Recurrent peritonsillar abscess
2) Massive tonsils causing acute airway obstruction
3) Patient already under general anesthesia due to comfort issues or poor exposure.

Front 70

Describe the three common transcervical incision and drainage approaches

Back 70

Choice depends on involved spaces:
1) Modified blair incision (parotid)
- parotid space
- temporal or infratemporal fossa
- submandibular or parapharyngeal space (with extension of neck incision

2) Horizontal lateral neck incision upper neck (2cm below mandible body)
- masticator space (lower border of mandible and staying along lateral surface)
- submandibular space (between posterior belly of diagastric and mandible body)
- sublingual space (lateral to anterior digastric body with blunt spreads through mylohyoid muscle)
- parapharyngeal space/pterygomaxillary space

3) Horizontal lateral neck incision mid-neck (level 3 at cricoid cartilage)
- Retropharyngeal/danger/prevertebral spaces
- dissection medial to carotid sheath (retracted laterally) and lateral to strap muscles (retracted medially)
- deep cervical fascia and paraspinous muscles identified
- blunt dissection superior (skull base) to inferior (mediastinum)

Front 71

What is the most common etiology of ludwig's angina?

Back 71

dental origin

Front 72

Ludwig's angina spreads rapidly though the ___________.

Back 72

fascial planes (not lymphatics

Front 73

What is the typical description of the feel of the neck in a pt with Ludwig's angina?

Back 73

a woody, indurated neck

Front 74

What is the mortality rate of cavernous sinus thrombosis?

Back 74

30-40%

Front 75

What is Lemierre syndrome?

Back 75

Thrombophlebitis of the internal jugular vein
- a possible complication of deep neck infections
- usually caused by the bacterium Fusobacterium necrophorum (anaerobic gram-negative bacillus)
- bacterium spreads to the IJ from tonsillar veins where endotoxin causes platelet aggregation.
- associated with pharyngitis, spiking "picket fence" fevers"

Front 76

What is the Tobey-Ayertest?

Back 76

Compression of the thrombosed IJ (in Lemierre syndrome) during spinal tap does not increase CSF pressure as opposed to the contralateral side.

Front 77

Carotid artery pseudoaneurysm or rupture is associated with infection of which cervical spaces?

Back 77

retropharyngeal and parapharyngeal space
- mortality rate 20-40%
- internal carotid artery is the cause 49% of time.

Front 78

What are signs of carotid artery pseudoaneurysm or rupture in a patient with deep neck infection?

Back 78

Pulsatile neck mass
Horner syndrome
Palsies of CN 9-12
Expanding hematoma
Neck ecchymosis
Sentinel bright red bleed from nose or mouth
Hemorrhagic shock

Front 79

Mediastinitis is associated with infections of which cervical spaces?

Back 79

retropharyngeal space (most common; superior mediastinum)

danger space (posterior mediastinum to diaphragm)

- tx of mediastinitis is best with a combined transcervical and transthoracic incision and drainage

Front 80

What is the most common cause of necrotizing fasciitis of the neck?

Back 80

dental infections (mixed aerobic and anaerobic flora)
- mortality is 20-30%
- neck CT shows tissue gas in 50% of cases