Download Head and neck fascia and compartments: No space for spaces

CLINICAL REVIEW
David W. Eisele, M.D., Section Editor
Head and neck fascia and compartments: No space for spaces
Alice K. Guidera, BSc, MBChB,1* Patrick J. D. Dawes, MBChB, FRCS,1 Amy Fong, MBBS, FRANZCR,2 Mark D. Stringer, MS, FRCS,3
1
Department of Surgical Sciences, Dunedin School of Medicine, Dunedin, New Zealand, 2Department of Radiology, Southern DHB, Dunedin, New Zealand, 3Department of Anatomy, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand.
Accepted 24 July 2013
Published online 29 January 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23442
ABSTRACT: An accurate understanding of the arrangement of cervical
fascia and its associated compartments is essential for differential diagnosis, predicting the spread of disease, and surgical management. The
purpose of this detailed review is to summarize the anatomic, clinical,
and radiological literature to determine what is known about the
arrangement of cervical fascia and to highlight controversies and consensus. The current terminology used to describe cervical fascia and
compartments is replete with confusing synonyms and inconsistencies,
creating important interdisciplinary differences in understanding. The
term ‘‘spaces’’ is inappropriate. A modified nomenclature underpinned
by evidence-based anatomic and radiologic findings is proposed. This
should not only enhance our understanding of cervical anatomy but also
C
facilitate clearer interdisciplinary communication. V
2014 Wiley
Periodicals, Inc. Head Neck 36: 1058–1068, 2014
INTRODUCTION
A contributing factor is the variability of what is meant by
‘‘fascia.’’ Definitions usually refer to an organized arrangement of connective tissue that can be discerned macroscopically.6–9 This is often limited to the fibrous connective tissue
that forms sheets or sheaths around structures,7,10 but the
International Fascia Research Congress recently broadly
redefined fascia as ‘‘the soft tissue component of the connective tissue system that permeates the human body’’ including
‘‘all fibrous connective tissues, aponeuroses, ligaments, tendons, retinaculae, joint capsules, organ and vessel tunics, the
epineurium, the meninges, the periostea, and all the endomysial and intermuscular fibers of the myofasciae.’’10 The classification of fascia is similarly variable with groupings based
on developmental origin, function, or appearance.9,11–13 Fascia can vary between individuals according to mechanical
stress, age, and disease processes.14–16
This report reviews historic and modern anatomic, clinical,
and radiologic studies of head and neck fascia with the purpose of identifying areas of consensus and controversy. A
modified nomenclature that has the potential to encourage
greater cross-disciplinary understanding of head and neck
fasciae and its associated compartments is proposed.
Historically, anatomic and clinical studies have described
cervical fascia in the context of the spread of infection and
surgical management of disease.1,2 These provided the
foundation for modern radiology texts that focus on the
contents of named ‘‘spaces,’’ which is essential in differential diagnosis.3,4 However, as surgical technology advances,
a more precise understanding of fascial arrangements and
their variations becomes imperative. For example, endoscopic and robotic surgery offer access to previously inaccessible areas and provide new approaches to standard
procedures with reduced morbidity.
A recent review of recommended texts for radiology
and surgery trainees and students of anatomy highlighted
widespread confusion about both the layers of cervical
fascia and their potential spaces.5 Not only were descriptions of fascial arrangements and definitions of spaces
inconsistent and unclear, but the terminology was variable
and open to misinterpretation. The names used to describe
the fascial layers around the parapharyngeal, submandibular, and visceral spaces were particularly confusing.
KEY WORDS: head, neck, fascia, anatomy, terminology
METHODS
*Corresponding author: A. K. Guidera, Department of Surgical Sciences, Dunedin School of Medicine, PO Box 913, Dunedin 9054, New Zealand. E-mail:
[email protected]
Contract grant sponsor: This review was completed as part of ongoing research
funded by The Foundation for Surgery Research Scholarship, Royal Australasian College of Surgeons; a Dunedin School of Medicine Clinical Research
Scholarship, University of Otago; and The Richard Stewart Scholarship awarded
by The Dunedin Basic Medical Sciences Course Trust, Dunedin School of Medicine, University of Otago.
1058
HEAD & NECK—DOI 10.1002/HED
JULY 2014
An Ovid MEDLINE (1946–July 2012) search was conducted using the MeSH terms: ‘‘fascia,’’ ‘‘neck,’’ and
‘‘anatomy,’’ ‘‘radiology’’ or ‘‘surgery,’’ and keywords
‘‘deep cervical fascia,’’ ‘‘cervical fascia,’’ ‘‘prevertebral
fascia,’’ ‘‘pretracheal fascia,’’ ‘‘investing fascia,’’ and
‘‘superficial cervical fascia.’’ Further searches were conducted using the keywords ‘‘masticator space,’’ ‘‘submandibular
space,’’
‘‘retropharyngeal
space,’’
HEAD
‘‘parapharyngeal space,’’ ‘‘lateral pharyngeal space,’’
‘‘prevertebral space,’’ ‘‘visceral space,’’ and ‘‘deep neck
space,’’ all limited to ‘‘human.’’ Relevant original
research articles were supplemented by additional references obtained from article reference lists.
Illustrations were created in Adobe Illustrator (CS5.1)
from 2 sources: plastinated E12 axial slices (2.5-mm thickness) through the head and neck of a 65-year-old female
cadaver available through the W.D. Trotter Anatomy
Museum at the University of Otago; and from anonymized
normal MRIs obtained after institutional ethics committee
approval (LRS/11/EXP/013).
Layers of cervical fascia
For the purposes of this review, discussion is limited to
fascia that is traditionally described as delineating potential spaces within the head and neck. The pharyngobasilar
fascia and fasciae that might otherwise be regarded as a
tendon or ligament are not included.
Superficial cervical fascia
The variable definition of fascia is the root of much of
the confusion surrounding the superficial cervical fascia
(SCF). Some authors describe this as a continuous sheet
of fascia extending from the head and neck to the thorax
and axillae,1,2,17 whereas others use the term to indicate a
layer indistinguishable from,18 or synonymous with,19,20
the subcutaneous fat. The term ‘‘superficial cervical fascia’’ has been removed from the current reference source
on anatomic nomenclature because it no longer represents
a standard description.9 In the neck, the SCF contains the
platysma and superficial lymph nodes1,18,19,21,22 and is
loosely arranged to facilitate neck movement.
Craniad to the mandible, the SCF continues as the fascia
that ‘‘invests’’ the muscles of facial expression and occipitofrontalis in the scalp1,19,23; it is referred to by different
names as it progresses cranially.24 Interest in this layer was
renewed with the popularization of facelift surgery and the
definition of the superficial musculoaponeurotic system
(SMAS).22,25–27 Starting at the vertex, the galea aponeurotica, occipitofrontalis, and orbicularis oculi muscles are in
continuity with the temporoparietal fascia24,28 and, inferior
to this, the SMAS over the zygomatic arch25,28 (although
not all authorities agree on the latter).8 This layer, which
incorporates the muscles of facial expression, is then continuous with the SCF and platysma in the neck.26,29,30
Beneath the temporoparietal fascia is a layer of loose but
vascular connective tissue often called the innominate fascia by plastic surgeons31; this is continuous with the subgaleal layer in the scalp but its limits are not well described.
The relationship between the SMAS and the SCF is
contentious: descriptions range from the two being synonymous,26,32 related,33 distinct,27 or there being no such
layer as the SMAS as originally defined by Mitz and
Peyronie.22,25,29 These predominantly histologic studies
have also suggested that the SCF (rather than the superficial layer of deep cervical fascia) forms the lateral fascial
layer over the parotid.26,29,30
AND NECK FASCIA AND COMPARTMENTS
‘‘completely encircling the neck,’’1,17–19,21,24,34 although it
has been suggested that it is incomplete between the sternocleidomastoid and trapezius muscles.35,36 A simplified
‘‘rule of twos’’ describes the SLDCF as enclosing 2 glands
(submandibular and parotid), 2 muscles (sternocleidomastoid and trapezius), and 2 ‘‘spaces’’ (suprasternal space and
the ‘‘subvaginal’’ space of the posterior triangle).17,19,34
The relationship between the SLDCF and the middle layer
of deep cervical fascia (MLDCF) is variously described.
Some authors report that they are fused at several sites: at
the hyoid; along the superolateral border of the anterior belly
of omohyoid continuing along its posterior belly into the posterior triangle; where the MLDCF covers the sternothyroid
and thyrohyoid1; and with the buccopharyngeal fascia.23
Superior to the hyoid, the SLDCF attaches to the mandible and styloid process, fusing with the sheath around the
digastric, and splitting to enclose the submandibular gland
separating it from hyoglossus and the superior constrictor
muscle on its deep surface1; a thickening of this layer contributes to the stylomandibular ligament.17,37,38 Superior
to the mandible, the SLDCF splits into 2 laminae, the
lateral lamina covering the masseter and attaching to the
zygomatic arch1,39 and the medial lamina running on
the deep surface of the pterygoid muscles and attaching
to the skull base medial to the foramen ovale.1,23,38–41
The most cranial extension of the SLDCF is disputed.
Some authors refer to the temporal fascia that extends up
over the temporalis to attach to the superior temporal
line8,42 as a continuation of the SLDCF,1,23,39,41,43 whereas
others limit the superior extent to the zygoma18,34,39,44 or
extend it into the aponeurotic layer of the scalp.23 There is
also debate about whether the SLDCF completely invests
the parotid gland26,29,30 and its relationship to the masseteric fascia.1,23,39 This is not a new argument.43 More
recent studies suggest that the SLDCF is continuous with
the fascia covering the masseter muscle but that the parotid
gland lies laterally and is covered with fascia of a different
origin, variably described as SCF, innominate fascia,31 or a
‘‘platysmal’’ layer.22,27,29,30
Middle layer of deep cervical fascia. This is described as
having muscular and visceral divisions1,2,17,19,34,37,38 or
simply a visceral part.18,39,44–46
Muscular layer. This term is usually used in conjunction
with ‘‘visceral fascia’’ to describe that portion of the
MLDCF that ensheaths the strap muscles.17,19,47 Some
authors subdivide it into sternohyoid/omohyoid and sternothyroid/thyrohyoid components,1,47 whereas others refer
to it generally as the ‘‘strap fascia,’’35 or even part of the
SLDCF.21,34 This layer runs between the bony attachments of these muscles.
Deep cervical fascia
Visceral layer. This has been used to describe all the components of the MLDCF19 or only that part surrounding the larynx, pharynx, trachea, esophagus, and thyroid.1,18 The latter
is generally agreed to blend inferiorly with the fibrous pericardium1,17–19,34,37,38,44 but there is disagreement as to whether it
extends superiorly only to the level of the hyoid bone34,38,44
or if a posterior continuation reaches the skull base.1,17–19,39,47
Superficial layer of deep cervical fascia. The superficial layer
of deep cervical fascia (SLDCF) is usually described as
Buccopharyngeal fascia. The prefix ‘‘bucco’’ refers to the
superior extension of this layer that is stated to continue
HEAD & NECK—DOI 10.1002/HED
JULY 2014
1059
GUIDERA ET AL.
TABLE 1. Historical and suggested terms for the cervical fascia.
Layer
Other terms
SCF
DCF
Superficial layer
Middle layer
Deep layer
Suggested term
Galea aponeurotica, temporoparietal fascia,
superficial temporal fascia, subcutaneous
tissue, platysmal layer, and
subcutaneous musculoaponeurotic system
Subcutaneous tissue
Subaponeurotic layer of galea aponeurotica,
parotidomasseteric fascia
Investing fascia, enveloping layer, general or deep
investing fascia, great cervical sheath, external layer,
and anterior layer29,30
Muscular division
Sterno-omohyoid layer
Sternothyroid-thyrohyoid layer
Visceral fascia, pretracheal fascia, prethyroid fascia,
and buccopharyngeal fascia Pharyngomucosal fascia
Prevertebral, perivertebral, and paravertebral
Scalene fascia
Alar fascia
Masticator fascia
Submandibular fascia
Sternocleidomastoid-trapezius fascia
Strap muscle fascia
Visceral fascia
Perivertebral fascia (prevertebral
for anterior part only)
Alar fascia
Abbreviations: SCF, superficial cervical fascia; DCF, deep cervical fascia.
over the buccinator muscle.19 This term has been used to
refer to the whole ‘‘visceral’’ component of the
MLDCF,1,4,17,39,48 or to a discrete entity that is adherent
to the pharynx and either continuous with,1,46 or separate
from23,34 the MLDCF.
Pretracheal fascia. This term is rarely used in isolation. With
the exception of 1 reference restricting the term to that portion of the MLDCF lying anterior to the trachea,34 ‘‘pretracheal’’ was synonymous with the MLDCF surrounding the
larynx, pharynx, trachea, esophagus, and thyroid.1,17,34,44
Other terms in the literature include the ‘‘pharyngomucosal fascia’’ to describe the purely visceral portion of
the MLDCF45 and the ‘‘viscerovascular system’’ of fascia
to describe the fascia surrounding the viscera of the neck
and the carotid sheath.43,47
Deep layer of deep cervical fascia
This is consistently described as encompassing the vertebral column and paravertebral muscles, attaching to the
transverse and spinous processes of the cervical vertebrae.1,2,17,39 As it passes laterally over the scalene muscles,
it forms the floor of the posterior triangle. The term ‘‘prevertebral’’ is used to describe either the complete circumferential layer of fascia2,45 or just that part covering the
prevertebral muscles anteriorly between the transverse processes.1,21,34,37,38 Laterally, it is described as being continuous with the axillary sheath and the suprapleural membrane
(Sibson’s fascia). Caudally, it is stated to extend to the coccyx1,2,17,19 or ‘‘fades away’’ in the thorax.34
The alar fascia is generally stated to be a division of
the deep layer of deep cervical fascia (DLDCF) spanning
between the transverse processes of the cervical vertebrae
anterior to the prevertebral fascia and fusing laterally
with the carotid sheath.1,2,17,19,21
Carotid sheath
Modern radiologic and surgical sources frequently
describe the carotid sheath as being composed of all 3
1060
HEAD & NECK—DOI 10.1002/HED
JULY 2014
layers of DCF,4,20,39,41,49–52 but offer little explanation as
to how this occurs. In their seminal article in 1938, Grodinsky and Holyoke1 suggested that the carotid sheath
receives contributions from the alar fascia (DLDCF)
throughout its length, from the SLDCF adjacent to the
digastric and sternocleidomastoid muscles, and from the
MLDCF where it covers the sternothyroid. A few authors
offer alternative descriptions stating that the carotid
sheath is made up of the SLDCF and pretracheal layers
of fascia,53 or is independently derived but receives a
contribution medially from the alar fascia.45 Older literature contains even more diverse statements about the
composition of the carotid sheath.18,37,47,54
Histologic studies have found that the carotid sheath is
always present in its upper third55 and distinct from other
fascial layers.15 The thickness of the carotid sheath varies
between individuals and at different levels in the neck.15
It seems to form a barrier to metastatic disease.56 It is
developmentally distinct from the prevertebral fascia and
is intimately related to the fascia enclosing omohyoid14
and the visceral compartment15 in part of its course.
Recommendations on cervical fascia
The terms ‘‘superficial’’, ‘‘middle’’, and ‘‘deep’’ layers
of cervical fascia are confusing and should be abandoned
for several reasons. First, the term ‘‘superficial fascia’’ is
poorly defined and variably applied.7,9,12,31,57,58 It can
refer to the layer of fatty connective tissue immediately
deep to the dermis,12 or more specifically to a membranous layer within the fatty subcutaneous tissue.59 Second,
there is obvious confusion in having a term that contains
more than 1 descriptor (eg, ‘‘superficial’’ and ‘‘deep’’).
Third, the ‘‘middle’’ layer is actually anterior to the
‘‘deep’’ layer, which, in places, is relatively superficial.
Finally, these terms imply distinct fascial layers that are
independent of each other, whereas at some sites they are
closely associated and even fused.
Adopting the following terms (Table 1) may reduce
confusion:
HEAD
‘‘Superficial fascia’’ should be replaced by ‘‘subcutaneous tissue’’ as recommended in Terminologia Anatomica9;
in many regions, this may contain a readily identifiable
membranous layer and/or cutaneous muscles. Although
there is some debate about the existence of SMAS, it
seems to be a feature of this layer but its relationship to
the parotid gland is controversial.
Fascia that invests muscle is best described according
to its related functional muscle group. Thus, the masticator fascia covers the muscles of mastication (and therefore
includes the temporal, masseteric, and pterygoid fasciae)
and defines the boundaries of the masticator space. The
strap muscle fascia invests sternohyoid, thyrohyoid, sternothyroid, and omohyoid and can be distinguished from
both the fascia of the overlying sternocleidomastoid and
that surrounding the underlying visceral and carotid compartments, although they may be adherent in places.1,14
The fascia of the styloid muscles and posterior belly of
digastric is often ignored in discussions of the DCF, but
the proposed classification would allow this fascia to be
called the ‘‘styloid fascia.’’ This scheme would also recognize the sternocleidomastoid-trapezius fascia as investing these muscles and bridging the gap anteriorly
between the sternocleidomastoid muscles; until the controversy about whether this fascia bridges the posterior
triangle is resolved, there is no need to consider revising
this to separate sternocleidomastoid and trapezius
fasciae.35,36
The fascia passing between the hyoid and the mandible
that splits to encompass the submandibular gland and
forms the floor of the submandibular space would be
called the ‘‘submandibular fascia’’ (distinct from the capsule of the submandibular gland).
The terms ‘‘pretracheal’’ and ‘‘buccopharyngeal’’ are
ambiguous and anatomically imprecise and should be
abandoned. The fascia surrounding the larynx/trachea,
pharynx/esophagus, and thyroid should be designated
‘‘visceral fascia.’’
The confusion surrounding the extent of the ‘‘DLDCF’’
seems to be limited to texts.5 In the anatomic literature,
this layer extends between the transverse processes of the
cervical vertebrae anterior to the prevertebral muscles, is
continuous laterally with the scalene fascia, and extends
posteriorly to reach the cervical spinous processes.
Because this layer surrounds the vertebral column and its
musculature, the term ‘‘perivertebral fascia’’ would be
more appropriate for fascia lateral and posterior to the
transverse processes45,52,53 with prevertebral fascia defining the fascia on the anterior surface of the prevertebral
muscles. The term ‘‘alar fascia’’ can be retained to
describe the discrete layer of fascia immediately anterior
to the prevertebral fascia spanning between the transverse
processes of the cervical vertebrae.
The carotid sheath surrounds the internal carotid artery,
internal jugular vein, and lower cranial nerves. It is connected to and reinforced by adjacent fascia at different
sites (eg, the alar, visceral, and strap muscle fascia).
Fascial ‘‘spaces’’ and planes
Defining ‘‘spaces’’ in the head and neck is similarly
prone to misinterpretation and confusion. The Oxford
English Dictionary defines a space as ‘‘a continuous area
AND NECK FASCIA AND COMPARTMENTS
or expanse that is free, available, or unoccupied.’’60 In
the neck, a ‘‘space’’ may refer to a functional
unit,2,50,52,53 or anatomic region bounded by fascia,39,61–63
or a region bounded by bones, muscles, fascia, or skin.23
With advances in radiology, ‘‘spaces’’ have often been
defined by their anatomic contents (eg, blood vessels,
lymph nodes, nerves, and viscera) rather than their fascial
perimeters, and have tended to become regions containing
a set of defined structures easily identifiable on crosssectional imaging.41,53 Most ‘‘spaces’’ in the body are in
fact
either
‘‘potential
spaces’’2,23,64,65
or
19,37,38
compartments.
For discussion purposes, ‘‘spaces’’ in the head and
neck can be roughly divided into cranial (related to the
skull and face) and cervical (related to the cervical spine),
although these distinctions are not absolute.
Cranial fascial ‘‘spaces’’
The cranial fascial ‘‘spaces’’ include the spaces related
to the parotid gland, muscles of mastication, and the submandibular gland.
Parotid space. The term ‘‘parotid space’’ is used almost
exclusively in the radiologic literature.41,45,66,67 It
describes the potential space created by the fascia that
encloses the parotid gland,4,39,41,66,67 although, as noted
previously, the precise fascial arrangement in this area is
debatable.22,29 The deep lobe of the parotid gland extends
posteromedial to the mandible and forms a lateral border
of the parapharyngeal space. Although anatomic studies
suggest that the fascia covering this aspect of the parotid
is complete,1 the spread of infection from the parotid to
the parapharyngeal space noted in the clinical literature
indicates that it does not provide a functional barrier.43,67
Masticator space. This was originally defined as a discrete
region limited by the masseter, pterygoid, and temporal
muscles in continuity with but not including the superficial
and deep temporal spaces. Some anatomic studies have
taken the zygomatic arch as the superior extent of this
space but agree that there is free communication with the
superficial and deep temporal spaces.1,2,23,43 Other studies
have referred to a single masticator space that also includes
the buccal fat pad anterolaterally,68,69 or subdivided the
space into suprazygomatic, retrozygomatic, infratemporal,
and nasopharyngeal regions.4,19,23,39,45,50,61
Superficial and deep temporal spaces. The superficial temporal space is the space between the temporal fascia covering the temporalis and the temporoparietal fascia. The deep
temporal space lies between the temporalis, the periosteum
of the temporal bone, and the lateral pterygoid muscle.17,43
Both spaces freely communicate anteriorly and the deep
temporal space communicates with the masticator space.
Infratemporal space (fossa). To anatomists, this is the postmaxillary region between the ramus of the mandible laterally and the pharyngeal wall medially inferior to the
zygomatic arch.8 Various boundaries delimited by
muscles and the parotid gland are described in the clinical
literature70–75 with some radiologists choosing to include
HEAD & NECK—DOI 10.1002/HED
JULY 2014
1061
GUIDERA ET AL.
both the masticator and parotid spaces as subdivisions of
this fossa.76
Buccal space. Originally described as the space occupied
by the buccal fat pad anterior to the masseter muscle,23 it
has often been neglected in discussions of spaces in the
head and neck. The buccal space is bordered anterolaterally by subcutaneous tissue and the zygomaticus major,
minor, and risorius muscles,23,41,77 medially by the buccinator, and posteriorly by the mandible, masseter, and
pterygoid muscles. Continuity of the buccal fat pad with
the temporoparietal fat pad is well described.23,41,45,68,69,77
Infection in this region is stated to always involve the
masticator compartment,66 and, although clinical studies
report early confinement of infection, spread into the
parotid, temporal, and submandibular spaces occurs with
disease progression.61,69
Submandibular space. This term (and the archaic ‘‘submaxillary space’’) has been used to describe 2 different
anatomic regions: first, the space inferior to the mylohyoid bounded inferiorly by the attachment of the SLDCF
between the mandible and hyoid41,45; and second, the
space superior and inferior to the mylohyoid, including
the floor of mouth.1,3,19,43 When the latter definition is
used, the submandibular space is subdivided into a sublingual space superior to the mylohyoid, a submaxillary
space inferior and lateral to the mylohyoid, and a submental space centrally.2,3
Several cadaver dissection studies, some of which have
incorporated the injection of colored gelatin, have shown
free communication between the submandibular and parapharyngeal spaces.1,19,43 However, other dissection studies78 and clinical and radiologic observations do not
support such a communication.69
Cervical fascial ‘‘spaces’’
The cervical fascial ‘‘spaces’’ include the historical
‘‘deep spaces’’ (parapharyngeal, retropharyngeal, danger,
prevertebral, and visceral spaces) as well as the more
recently defined pharyngeal mucosal and anterior and
posterior cervical spaces.
Parapharyngeal space. A host of synonyms have been
used for this space. It is commonly described as an
inverted pyramid, cone, funnel, or triangle with the skull
base superiorly and the greater cornu of the hyoid bone
or mandible inferiorly,1,2,20,38,78,79 although this concept
has been challenged.80 Laterally, it is bordered by the
medial pterygoid muscle and parotid gland, posteriorly by
the prevertebral muscles or carotid sheath (depending on
the definition), and medially by the visceral fascia covering the pharyngeal muscles.1,4,18,78,81 Some authors subdivide the space into the anterior (prestyloid) and posterior
(poststyloid) compartments.41,80,82 This subdivision and
the communications between this space and adjacent
compartments are controversial.
Considering the first of these controversies, numerous
structures have been suggested to subdivide the parapharyngeal space: the styloid muscles and posterior
belly of digastric (the so-called ‘‘styloid dia1062
HEAD & NECK—DOI 10.1002/HED
JULY 2014
phragm’’)75,83,84; the tensor veli palatini and its fascia40,84; the ‘‘stylopharyngeal aponeurosis’’18,19,38,78,85;
and the levator veli palatini and its fascia.86 To compound the confusion, some authors have added a further
subdivision, namely a third medial compartment (retropharyngeal)81,87 or a posterior hypoglossal compartment.88 Some studies have reported free communication
between these subdivisions,20,38,47,64 whereas others
have found the converse.18,19,37,88
The second controversy centers on whether the parapharyngeal space is entirely enclosed18,78 or communicates with the parotid, submandibular, and/or
retropharyngeal spaces.1,20,37,38,47,63,64 Injection of gelatin
into the parapharyngeal space of cadavers has shown free
communication with the retropharyngeal space1 but no
communication in the reverse direction.37
Carotid space. This is bound by the carotid sheath. It is
said to be susceptible to infection from any of the surrounding layers and compartments,17,44,47 but clinical
studies have found that disease tends to be reasonably
isolated along the course of the sheath.2,19
Pharyngeal mucosal space. This term has appeared in the
radiologic literature4,89 to describe the space deep to the
visceral layer of DCF encircling the pharyngeal constrictor muscles between the skull base and cricoid cartilage;
nasopharyngeal, oropharyngeal, and hypopharyngeal divisions are reported.89 The pharyngeal mucosa represents
the deepest limit of this space.4,39,50,76,89 The pharyngeal
mucosal space is not the same as the ‘‘peritonsillar
space,’’ which has been described in surgical texts
because this is the potential space between the capsule of
the palatine tonsil and the superior constrictor and palatal
muscles.2,19,86,90 Nevertheless, the peritonsillar space lies
within the pharyngeal mucosal space.
Retropharyngeal and danger spaces.
Building on earlier
studies,11,38,47,54 Grodinsky and Holyoke1 described 2
spaces bounded by visceral fascia anteriorly, prevertebral
fascia posteriorly, and the alar fascia in between; these
have been reaffirmed in modern studies48 and become
known as the retropharyngeal space (anterior) and the
danger space (posterior).1 The retropharyngeal space contains lymph nodes, whereas the danger space has no specific contents.48 This division into 2 ‘‘spaces’’ is
reinforced in the radiologic literature,4,79,82,91 but some
authors either do not describe a ‘‘danger space’’43,45,52,69
or consider the retropharyngeal and danger spaces as a
single functional space.4
Craniad to the hyoid, the retropharyngeal space is
stated to either communicate freely with the parapharyngeal space1,20,38,47 or be limited by the lateral extent of the
pharynx.11,37,39,78 Radiologic studies have reported no
communication with the parapharyngeal space in general,82 or with its ‘‘prestyloid’’92 or ‘‘poststyloid’’3 subdivisions. Inferior to the hyoid, the retropharyngeal space is
stated to extend anterolaterally around the viscera.1 It has
also been suggested that it communicates with the visceral space3,11,19,85 between the level of the thyroid cartilage and inferior thyroid artery.3,79 The inferior limit of
the retropharyngeal space is variably described as lying
HEAD
AND NECK FASCIA AND COMPARTMENTS
TABLE 2. Cranial ‘‘spaces’’ and their contents.
Previous terms, with subdivisions
Parotid space
Masticator space, buccomasseteric
region
Suprazygomatic
Infratemporal
Nasopharyngeal
Retrozygomatic
Superficial and deep temporal spaces
Buccal space
Submandibular space
Submaxillary
Sublingual
Submental
Contents
Suggested term
Parotid gland, retromandibular vein, facial nerve,
external carotid artery, lymph nodes
Mandible (or just the alveolar ridge), masseter,
medial and lateral pterygoid muscles,
mandibular division of trigeminal
nerve
Extension of buccal fat
Superficial: superficial temporal vessels and
branches of the auriculotemporal and facial
nerves, temporoparietal fat pad
Buccal fat pad, parotid duct
Hypoglossal nerve, lingual nerve, submandibular
and sublingual glands, submandibular duct, lymph nodes
between the sixth cervical (C6) and fourth thoracic vertebrae (T4),1,3,45 at T1 to T2,2,17,62,93 T3,50 T2 to T6,94 or
in the ‘‘upper mediastinum.’’4,95
Prevertebral or perivertebral space.
The ‘‘prevertebral
space’’ is usually regarded as a potential space between
the DLDCF anteriorly and the transverse processes of
the vertebrae posteriorly, extending from the skull base
to the coccyx.1,2,19,48 An alternative definition is a rectangular space between the MLDCF anteriorly and the
DLDCF posteriorly, extending to the mediastinum (ie,
the equivalent of the retropharyngeal space described
above).11,37,38,85
Others
describe
a
‘‘perivertebral’’45,52,53 or ‘‘prevertebral’’41,94 space enclosed by
fascia extending round to the spinous processes posteriorly; this space has been divided into anterior or ‘‘prevertebral’’ and posterior or ‘‘paraspinal’’ portions by
fascial attachments to the transverse processes of the
cervical vertebrae.50,95 In these schemes, the prevertebral space is stated to extend down to T3,4 the pericardium,41 or the coccyx.52,95
Anterior and posterior cervical spaces. The radiologic literature refers to ‘‘spaces’’ in the regions occupied by the
anterior and posterior triangles of the neck.8,96,97 A ‘‘posterior cervical space’’ is described between the DLDCF
covering
the
scalene
muscles
and
the
sternocleidomastoid–trapezius fascia; it is limited anteromedially by the carotid sheath. The posterior cervical
space theoretically communicates with the axilla but
spread of infection between these sites is uncommon.1
Anterior to the sternocleidomastoid is a separate smaller
fat-filled ‘‘anterior cervical space,’’ lying between the
superficial and middle layers of DCF, and extending from
the hyoid bone to the clavicles.93,97 Parker et al97
described a communication between this space and the
submandibular space, despite the presence of a firm fascial attachment of the SLDCF to the hyoid.2,19 Infections
in the anterior and posterior cervical spaces tend to be
localized or track toward the skin46,93 and therefore are
Parotid compartment
Masticator compartment
Submandibular compartment
not usually considered in the clinical literature on deep
neck infections.2,20 The real clinical utility of these spaces
relates to lymphadenopathy and the staging of metastatic
disease, but, for this purpose, lymph nodes are best
divided into levels defined by anatomic rather than fascial
relations.3,98–100
Visceral space. Much of the confusion about this ‘‘space’’
stems from the variable nomenclature applied to the
MLDCF (see above). Thus, the visceral space has been
described as a potential space between the trachea, esophagus, and thyroid, and their surrounding visceral fascia1 or,
alternatively, is seen as part of a larger space that includes
the carotid sheath.47,85 Some authors have divided the visceral space into anterior and posterior components,2,19 but
there is no convincing anatomic evidence to support this.
The space is reported to extend caudally as far as the tracheal bifurcation and/or arch of the aorta.1,2,11,19,47 The
radiologic literature more simply refers to a ‘‘visceral
space’’ containing the larynx/trachea, pharynx/esophagus,
and thyroid and parathyroid glands, enclosed within the
MLDCF.41,52,53,94,95 The American Head and Neck Society
describes this space as extending back to the alar fascia100
and there is confusion about whether it communicates
directly with the retropharyngeal space.
Recommendations on compartments
The concept of ‘‘spaces’’ assists with differential diagnosis, understanding the spread of disease, and clinical
management, including surgical access. However, the
term ‘‘compartment’’ is more appropriate than ‘‘space’’
as no part of the head or neck is ‘‘free, available, or
unoccupied.’’60 Compartments may be bounded by bone
and/or muscle, as well as fascia, and individual compartments may intercommunicate. The trend to subdivide
these compartments into smaller and smaller regions
should be resisted because this becomes progressively
less meaningful to clinical practice.
The following compartments, summarized in Tables 2
and 3, are suggested.
HEAD & NECK—DOI 10.1002/HED
JULY 2014
1063
GUIDERA ET AL.
TABLE 3. Cervical compartments and their contents.
Previous terms, with subdivisions
Parapharyngeal space, paranasopharyngeal,
lateral pharyngeal, peripharyngeal,
pharyngomaxillary, pterygopharyngomaxillary,
pterygopharygneal,
pterygomandibular, pharyngomasticatory,
and lateral pharyngeal cleft
Prestyloid/anterior/anterolateral
Poststyloid/retrostyloid/posterior/posteromedial
Carotid space, carotid sheath, vascular space
Retropharyngeal space
Danger space
Perivertebral space, paravertebral space,
perivertebral space
Prevertebral space
Paravertebral, perivertebral, paraspinal
Visceral space, pretracheal space, anterior
visceral space, previsceral space
Anterior cervical space
Posterior cervical space
Contents
Suggested term
Fat, tonsillar vessels,
ascending palatine artery
ICA, IJV, cranial nerves IX, X, XI
and XII, sympathetic plexus, and lymph nodes
Parapharyngeal compartment
ICA, IJV, cranial nerve X, sympathetic
plexus, and lymph nodes
Fat, lymph nodes (suprahyoid only)
No contents
Prevertebral muscles
Paraspinal muscles, phrenic nerve,
and cervical nerve roots
Pharynx, larynx, trachea, esophagus,
thyroid gland (1/2 parathyroid glands)
Lymph nodes
Lymph nodes, cranial nerve XI,
and cervical plexus
Carotid compartment
Retropharyngeal compartment
Prevertebral compartment
Perivertebral compartment
Visceral compartment
Levels 1 to 6
Abbreviations: ICA, internal carotid artery; IJV, internal jugular vein; IX, glossopharyngeal nerve; X, vagus nerve; XI, spinal accessory nerve; XII, hypoglossal nerve.
Parotid compartment. There is clear benefit in defining
this compartment for radiologic assessment. Surgery tends
to center around facial nerve preservation but fascial
arrangements are useful in analyzing disease spread, particularly in relation to the deep lobe of the parotid and
the parapharyngeal space.
Masticator compartment. This compartment is bound by
the masticator fascia. There is no clear clinical benefit
from subdividing the compartment into temporal, infratemporal, or retrozygomatic portions, as these are continuous
and inconsistently applied. The term ‘‘infratemporal fossa’’
is best avoided when describing fascial compartments.
Although the buccal region houses a subdivision of the
masticator compartment bordered laterally by subcutaneous
tissue, medially by visceral fascia covering buccinator, and
posteriorly by masticator fascia covering the masseter muscle, there is no obvious advantage from labeling this as a
separate ‘‘buccal compartment’’ because it is in continuity
with the masticator compartment and can be localized clinically by reference to the buccal fat pad.
Submandibular compartment. This comprises the potential
‘‘space’’ craniad and caudad to the mylohyoid muscle
bound inferolaterally by the fascia of the submandibular
compartment as it passes between the mandible and hyoid.
There is no discrete sublingual space. We recommend that
this potential space is known as the submandibular compartment, with ‘‘floor of mouth’’ (as advised by the American Joint Committee on Cancer)99 being used to describe
the ‘‘sublingual region’’ craniad to the mylohyoid.
Parapharyngeal and carotid compartments.
In the suprahyoid region of the neck, there are distinct carotid and
1064
HEAD & NECK—DOI 10.1002/HED
JULY 2014
parapharyngeal compartments. The terms ‘‘prestyloid’’
and ‘‘poststyloid,’’ although useful for traditional surgical approaches to the parapharyngeal compartment, are
not anatomically accurate and should be abandoned. The
current literature does not permit reliable conclusions
about the fascial arrangements and connections related
to the parapharyngeal compartment; in particular, the
relationship between the styloid muscles and the pharyngotympanic tube within the compartment is poorly
defined.
Retropharyngeal compartment.
Contemporary crosssectional imaging cannot reliably distinguish the fascial
layer between the retropharyngeal space and the danger
space. Clinically, treatment decisions on infections in this
region are based on physical findings and response to
antibiotics rather than whether the infection is in one
‘‘space’’ or the other. Therefore, it is more useful to consider a single retropharyngeal compartment. Further
investigations are needed to define the lateral and inferior
limits of this compartment.
Prevertebral and perivertebral compartments. The former is
situated anterior to the cervical vertebral bodies and transverse processes and bound anteriorly by prevertebral fascia. The latter is located posterior to the transverse
processes of the cervical vertebrae and enclosed by perivertebral fascia.
Visceral compartment. The precise fascial arrangement of
this compartment is not well understood and may vary
between individuals. Broadening the definition of the visceral compartment to the region encompassed by the visceral fascia seems appropriate. Whether it is in continuity
HEAD
AND NECK FASCIA AND COMPARTMENTS
FIGURE 1. (A–D) The layers of cervical fascia. (A) Subcutaneous tissue. (B) Masticator fascia, submandibular fascia, and sternocleidomastoidtrapezius fascia. The fascia covering the lateral surface of the parotid gland is controversial and therefore not shown. (C) Strap muscle fascia
(green) and perivertebral fascia (purple). (D) Visceral fascia (orange) and carotid sheath.
with the retropharyngeal space at any site is unclear.
Functionally, the visceral compartment is concerned with
the airway, deglutition, and endocrine functions. The
terms ‘‘pretracheal,’’ ‘‘previsceral,’’ and ‘‘anterior visceral’’ should no longer be used.
Adopting this scheme would allow consideration of a
‘‘strap muscle compartment’’ and a ‘‘sternocleidomastoidtrapezius compartment’’ because these are functional units
bound by fascia. However, recognition of these compartments has limited clinical utility.
The ‘‘pharyngeal mucosal space’’ and ‘‘anterior and
posterior cervical spaces’’ are not precise anatomic compartments and these terms are not currently used by surgeons. They have been introduced in the last few decades
for radiologic diagnosis. Pathology within the ‘‘pharyngeal mucosal space’’ is actually within the pharyngeal
submucosa. When describing lymph nodes during the
staging of malignant disease, levels I to VI as contained
described by the Union for International Cancer Control
staging system99,100 are appropriate descriptors.
CONCLUSIONS
This review of anatomic and radiologic literature demonstrates the confusion that exists about fascial layers and
‘‘spaces’’ in the head and neck. Controversy surrounds the
nomenclature, boundaries, and communications and further
research is required to clarify the anatomy of some regions.
HEAD & NECK—DOI 10.1002/HED
JULY 2014
1065
GUIDERA ET AL.
FIGURE 2. (A and B) Fascial layers of the head and face with associated compartments. (A) Oblique-coronal section with comparable CT scan demonstrating the cranial fascia (left) and compartments (right). (B) Comparable axial MRI at the level of the hard palate.
Naming fascial layers in functional terms and removing
confusing descriptors such as ‘‘superficial layer of deep’’
creates a less ambiguous classification. Thus, the ‘‘superficial cervical fascia’’ should be referred to as ‘‘subcutaneous tissue’’ and the layers of the ‘‘deep cervical
fascia’’ are better named according to their function and
gross anatomy (Table 1) (Figures 1-3). The term ‘‘space’’
should be avoided in preference to the more accurate
term ‘‘compartment.’’ Although some of the compartments in our scheme are identical to standard descriptions, others are different and offer a more rational
approach to classification. The ‘‘submandibular compartment’’ is a midline region bound superiorly by the tongue
and oral mucosa and inferiorly by the submandibular fascia; the mylohyoid lies within the compartment but does
not provide a functional subdivision. The ‘‘strap muscle
compartment’’ and its fascia is distinct from the ‘‘visceral
compartment.’’ The ‘‘carotid compartment’’ traverses the
whole neck and lies posterolateral to the styloid and its
associated muscles in the suprahyoid region; it should not
be considered part of the ‘‘parapharyngeal compartment,’’
which is a discrete region with different contents. The
‘‘retropharyngeal compartment’’ is divided by the alar
fascia, but because this cannot be reliably visualized by
current imaging, it is best to consider this as a single
compartment, rendering the term ‘‘danger space’’
obsolete.
By clearly defining fascial layers and their associated
compartments, the relationships between different
regions of the neck become better understood and anatomic and radiologic interpretations more congruent. Our
proposal for a common language underpinned by
1066
HEAD & NECK—DOI 10.1002/HED
JULY 2014
evidence-based anatomic findings should enhance understanding of the neck and facilitate clearer interdisciplinary communication.
FIGURE 3. A. Cervical fascial layers and associated compartments. B. Comparable axial MRI at the level of the thyroid
isthmus.
HEAD
Acknowledgment
We thank Robbie McPhee, Medical Illustrator/Graphic
Artist, Department of Anatomy, University of Otago, for
assistance with the images.
REFERENCES
1. Grodinsky M, Holyoke EA. The fasciae and fascial spaces of the head,
neck and adjacent regions. Am J Anat 1938;63:367–408.
2. Levitt GW. Cervical fascia and deep neck infections. Otolaryngol Clin
North Am 1976;9:703–716.
3. Som PM, Curtin HD. Head and neck imaging. 5th ed. American Journal
of Roentgenology. St Louis, MO: Elsevier Mosby; 2011. p 3080.
4. Harnsberger HR. CT and MRI of masses of the deep face. Curr Probl
Diagn Radiol 1987;16:141–173.
5. Guidera AK, Dawes PJ, Stringer MD. Cervical fascia: a terminological
pain in the neck. ANZ J Surg 2012;82:786–791.
6. Stedmans Medical Dictionary 28th ed. In: Stegmand J, editor. 28th ed.
Philadelphia: Lippincott, Williams and Wilkins; 2006.
7. Findley T, Chaudhry H, Stecco A, Roman M. Fascia research—a narrative
review. J Bodyw Mov Ther 2012;16:67–75.
8. Standring S, editor. Gray’s Anatomy: the anatomical basis of clinical
practice. Philadelphia: Elsevier Churchill Livingstone; 2005.
9. Terminologia Anatomica. International Anatomical Terminology. New
York: Thieme Stuttgart; 1998.
10. Third international fascia research congress.Basic science and implications for conventional and complementary healthcare. 2012 cited. Available at: www.fasciacongress.org/2012/about.htm. Accessed August 7,
2013.
11. Charpy A. Aponevroses du cou. In: Poirier P, editor. Traite d’anatomie
humaine. Paris: Maison et cie; 1912. pp 258–280.
12. Langevin HM, Huijing PA. Communicating about fascia: history, pitfalls,
and recommendations. Int J Ther Massage Bodywork 2009;2:3–8.
13. Kumka M, Bonar J. Fascia: a morphological description and classification
system based on a literature review. J Can Chiropr Assoc 2012;56:179–
191.
14. Miyake N, Hayashi S, Kawase T, et al. Fetal anatomy of the human
carotid sheath and structures in and around it. Anat Rec (Hoboken) 2010;
293:438–445.
15. Hayashi S. Histology of the human carotid sheath revisited. Okajimas
Folia Anat Jpn 2007;84:49–60.
16. Hayes MA. Abdominopelvic fasciae. Am J Anat 1950;87:119–161.
17. Everts EC, Echevarria J. The pharynx and deep neck infections. In: Paparella MM, Shumrick DA, editors. Otolaryngology. Philadelphia: W.B.
Saunders Company; 1973. pp 318–340.
18. Hall C. The parapharyngeal space: an anatomical and clinical study. Ann
Otol Rhinol Laryngol 1934;43:793–812.
19. Paonessa DF, Goldstein JC. Anatomy and physiology of head and neck
infections (with emphasis on the fascia of the face and neck). Otolaryngol
Clin North Am 1976;9:561–580.
20. Lindner HH. The anatomy of the fasciae of the face and neck with particular reference to the spread and treatment of intraoral infections (Ludwig’s)
that have progressed into adjacent fascial spaces. Ann Surg 1986;204:
705–714.
21. Beahrs OH, Gossel JD, Hollinshead WH. Technic and surgical anatomy
of radical neck dissection. Am J Surg 1955;90:490–516.
22. Gardetto A, Dabernig J, Rainer C, Piegger J, Piza–Katzer H, Fritsch H.
Does a superficial musculaponeurotic system exist in the face and neck?
An anatomical study by the tissue plastination technique. Plastic Reconstr
Surg 2001;111:664–672; discussion 673–675.
23. Kostrubala JG. Potential anatomical spaces in the face. Am J Surg 1945;
68:28–37.
24. Davidge KM, van Furth WR, Agur A, Cusimano M. Naming the soft tissue layers of the temporoparietal region: unifying anatomic terminology
across surgical disciplines. Neurosurgery 2010;67(3 Suppl Operative):
120–129; discussion 129–130.
25. Mitz V, Peyronie M. The superficial musculo-aponeurotic system
(SMAS) in the parotid and cheek area. Plast Reconstr Surg 1976;58:80–
88.
26. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and
deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr
Surg 1992;89:441–449; discussion 450–451.
27. Thaller SR, Kim S, Patterson H, Wildman M, Daniller A. The submuscular aponeurotic system (SMAS): a histologic and comparative anatomy
evaluation. Plast Reconstr Surg 1990;86:690–696.
28. Tellioglu AT, Tekdemir I, Erdemli EA, T€
uccar E, Ulusoy G. Temporoparietal fascia: an anatomic and histologic reinvestigation with new potential
clinical applications. Plast Reconstr Surg 2000;105:40–45.
29. Jost G, Levet Y. Parotid fascia and face lifting: a critical evaluation of the
SMAS concept. Plast Reconstr Surg 1984;74:42–51.
30. Jost G, Wassef M, Levet Y. Subfascial lifting. Aesthetic Plast Surg 1987;
11:163–170.
AND NECK FASCIA AND COMPARTMENTS
31. Accioli de Vasconcellos JJ, Britto JA, Henin D, Vacher C. The fascial
planes of the temple and face: an en-bloc anatomical study and a plea for
consistency. Br J Plast Surg 2003;56:623–629.
32. Jost G, Lamouche G. SMAS in rhytidectomy. Aesthetic Plast Surg 1982;
6:69–74.
33. Rees TD, Aston SJ. A clinical evaluation of the results of submusculoaponeurotic dissection and fixation in face lifts. Plast Reconstr Surg 1977;
60:851–859.
34. Du Plessis DJ. A synopsis of surgical anatomy. 11th ed. Bristol, England:
John Wright and Sons Ltd; 1975.
35. Nash L, Nicholson HD, Zhang M. Does the investing layer of the deep
cervical fascia exist? Anesthesiology 2005;103:962–968.
36. Zhang M, Lee AS. The investing layer of the deep cervical fascia does not
exist between the sternocleidomastoid and trapezius muscles. Otolaryngol
Head Neck Surg 2002;127:452–454.
37. Barlow D. The surgical anatomy of the neck in relation to septic lesions:
an investigation of the cervical connective tissue. J Anat 1936;70(Pt 4):
548–565.
38. Mosher HP. Deep cervical abscess and thrombosis of the internal jugular
vein. Laryngoscope 1920;30:365–375.
39. Babbel RW, Harnsberger HR. The parapharyngeal space: the key to unlocking the suprahyoid neck. Semin Ultrasound CT MR 1990;11:444–459.
40. Curtin HD. Separation of the masticator space from the parapharyngeal
space. Radiology 1987;163:195–204.
41. Bielamowicz SA, Storper IS, Jabour BA, Lufkin RB, Hanafee WN.
Spaces and triangles of the head and neck. Head Neck 1994;16:383–388.
42. Sinnatamby CS, editor. Last’s Anatomy. Regional and Applied. 12th ed.
Edinburgh, Scotland: Churchill Livingstone/Elsevier; 2011.
43. Coller F, Yglesias L. Infections of the lip and face. Surg Gynecol Obstet
1935;60:277–290.
44. Berkovitz BKB, Moxham BJ. A textbook of head and neck anatomy. Barcelona, Spain: Wolfe Medical Publications Ltd; 1988.
45. Mukherji SK, Castillo M. A simplified approach to the spaces of the
suprahyoid neck. Radiol Clin North Am 1998;36:761–780.
46. Beck AL. Deep neck infections. Part II: submaxillary region infection.
Ann Otol Rhinol Laryngol 1947;56:722–764.
47. Coller F, Yglesias L. The relation of the spread of infection to fascial
planes in the neck and thorax. Surgery 1937;1:323–337.
48. Ozlugedik S, Ibrahim Acar H, et al. Retropharyngeal space and lymph
nodes: an anatomical guide for surgical dissection. Acta Otolaryngol
2005;125:1111–1115.
49. Fruin ME, Smoker WR, Harnsberger HR. The carotid space of the infrahyoid neck. Semin Ultrasound CT MR 1991;12:224–240.
50. Harnsberger HR, Osborn AG. Differential diagnosis of head and neck
lesions based on their space of origin. 1. The suprahyoid part of the neck.
AJR Am J Roentgenol 1991;157:147–154.
51. Reede DL, Bergeron RT, McCauley DI. The CT evaluation of the normal
and diseased neck. Semin Ultrasound CT MR 1986;7:181–201.
52. Shah RR, Lewin JS. Imaging of the infrahyoid neck. Neuroimaging Clin
N Am 1998;8:219–234.
53. Anderson JC, Homan JA. Radiographic correlation with neck anatomy.
Oral Maxillofac Surg Clin North Am 2008;20:311–319.
54. Parsons FG. On the carotid sheath and other fascial planes. J Anat Physiol
1910;44(Pt 2):153–155.
55. Piffer CR. Mesoscopic and microscopic study of the carotid sheath. Acta
Anat (Basel) 1980;106:393–399.
56. Khafif–Hefetz A, Leider–Trejo L, Medina JE, Gil Z, Flis DM. The carotid
sheath: an anatomicopathologic study. Head Neck 2004;26:594–597.
57. Stecco C, Duparc F. Fasciae anatomy. Surg Radiol Anat 2011;33:833–
834.
58. Wendell–Smith CP. Fascia: an illustrative problem in international terminology. Surg Radiol Anat 1997;19:273–277.
59. Lancerotto L, Stecco C, Macchi V, Porzionato A, Stecco A, De Caro R.
Layers of the abdominal wall: anatomical investigation of subcutaneous
tissue and superficial fascia. Surg Radiol Anat 2011;33:835–842.
60. Oxford English Dictionary. Available at: http://oxforddictionaries.com/
definition/english/space?q5space. Accessed August 7, 2013.
61. Braun IF, Hoffman JC Jr. Computed tomography of the buccomasseteric
region: 1. Anatomy. AJNR Am J Neuroradiol 1984;5:605–610.
62. Barratt GE, Koopmann CF Jr, Coulthard SW. Retropharyngeal abscess—
a ten-year experience. Laryngoscope 1984;94:455–463.
63. Bass RM. Approaches to the diagnosis and treatment of tumors of the parapharyngeal space. Head Neck Surg 1982;4:281–289.
64. Heeneman H, Maran AG. Parapharyngeal space tumours. Clin Otolaryngol Allied Sci 1979;4:57–66.
65. Gidley PW, Ghorayeb BY, Stiernberg CM. Contemporary management of
deep neck space infections. Otolaryngol Head Neck Surg 1997;116:16–
22.
66. Yonetsu K, Izumi M, Nakamura T. Deep facial infections of odontogenic
origin: CT assessment of pathways of space involvement. AJNR Am J
Neuroradiol 1998;19:123–128.
67. Weber AL, Siciliano A. CT and MR imaging evaluation of neck infections with clinical correlations. Radiol Clin North Am 2000;38:941–968.
68. Gaughran GR. Fasciae of the masticator space. Anat Rec 1957;129:383–
400.
HEAD & NECK—DOI 10.1002/HED
JULY 2014
1067
GUIDERA ET AL.
69. Spilka CJ. Pathways of dental infections. J Oral Surg 1966;24:111–124.
70. Chan JY, Li RJ, Lim M, Hinojosa AQ, Boahene KD. Endoscopic transvestibular paramandibular exploration of the infratemporal fossa and parapharyngeal space: a minimally invasive approach to the middle cranial
base. Laryngoscope 2011;121:2075–2080.
71. Theodosopoulos PV, Guthikonda B, Brescia A, Keller JT, Zimmer LA.
Endoscopic approach to the infratemporal fossa: anatomic study. Neurosurgery 2010;66:196–202; discussion 202–203.
72. Vrionis FD, Cano WG, Heilman CB. Microsurgical anatomy of the infratemporal fossa as viewed laterally and superiorly. Neurosurgery 1996;39:
777–785; discussion 785–786.
73. McCool RR, Warren FM, Wiggins RH III, Hunt JP. Robotic surgery of
the infratemporal fossa utilizing novel suprahyoid port. Laryngoscope
2010;120:1738–1743.
74. Hartnick CJ, Myseros JS, Myer CM III. Endoscopic access to the infratemporal fossa and skull base: a cadaveric study. Arch Otolaryngol Head
Neck Surg 2001;127:1325–1327.
75. Bejjani GK, Sullivan B, Salas–Lopez E, et al. Surgical anatomy of the
infratemporal fossa: the styloid diaphragm revisited. Neurosurgery 1998;
43:842–852; discussion 852–853.
76. Cross RR, Shapiro MD, Som PM. MRI of the parapharyngeal space.
Radiol Clin North Am 1989;27:353–378.
77. Tart RP, Kotzur IM, Mancuso AA, Glantz MS, Mukherji SK. CT and MR
imaging of the buccal space and buccal space masses. Radiographics
1995;15:531–550.
78. Gaughran GR. The lateral pharyngeal cleft. Ann Otol Rhinol Laryngol
1959;68:1082–1096.
79. Unger JM, Chintapalli KN. Computed tomography of the parapharyngeal
space. J Comput Assist Tomogr 1983;7:605–609.
80. Li QY, Zhang SX, Liu ZJ, et al. The pre-styloid compartment of the parapharyngeal space: a three-dimensional digitized model based on the Chinese Visible Human. Surg Radiol Anat 2004;26:411–416.
81. Som PM, Biller HF, Lawson W. Tumors of the parapharyngeal space: preoperative evaluation, diagnosis and surgical approaches. Ann Otol Rhinol
Laryngol Suppl 1981;90(1 Pt 4):3–15.
82. Silver AJ, Mawad ME, Hilal SK, Sane P, Ganti SR. Computed tomography of the nasopharynx and related spaces. Part I: anatomy. Radiology
1983;147:725–731.
83. Dallan I, Seccia V, Muscatello L, et al. Transoral endoscopic anatomy of
the parapharyngeal space: a step-by-step logical approach with surgical
considerations. Head Neck 2011;33:557–561.
84. Maheshwar AA, Kim EY, Pensak ML, Kellers JT. Roof of the parapharyngeal space: defining its boundaries and clinical implications. Ann Otol
Rhinol Laryngol 2004;113:283–288.
1068
HEAD & NECK—DOI 10.1002/HED
JULY 2014
85. Testut L. Traite d’anatomie humaine: Aponevroses du cou. In: Latarjet A,
editor. Traite d’anatomie humaine. Paris: Libraire octave doin; 1928.
86. Katori Y, Kawase T, Ho Cho K, et al. Suprahyoid neck fascial configuration, especially in the posterior compartment of the parapharyngeal space:
a histological study using late-stage human fetuses. Clin Anat 2013;26:
204–212.
87. Lloyd GA, Phelps PD. The demonstration of tumours of the parapharyngeal space by magnetic resonance imaging. Br J Radiol 1986;59:675–683.
88. Shirakura S, Tsunoda A, Akita K, et al. Parapharyngeal space tumors:
anatomical and image analysis and findings. Auris Nasus Larynx 2010;37:
621–625.
89. Parker GD, Harnsberger HR, Jacobs JM. The pharyngeal mucosal space.
Semin Ultrasound CT MR 1990;11:460–475.
90. Levitt GW. The surgical treatment of deep neck infections. Laryngoscope
1971;81:403–411.
91. Weber AL, Baker AS, Montgomery WW. Inflammatory lesions of the
neck, including fascial spaces—evaluation by computed tomography and
magnetic resonance imaging. Isr J Med Sci 1992;28:241–249.
92. Sichel JY, Attal P, Hocwald E, Eliashar R. Redefining parapharyngeal
space infections. Ann Otol Rhinol Laryngol 2006;115:117–123.
93. Nyberg DA, Jeffrey RB, Brant–Zawadzki M, Federle M, Dillon W. Computed tomography of cervical infections. J Comput Assist Tomogr 1985;9:
288–296.
94. Davis WL, Harnsberger HR, Smoker WR, Watanabe AS. Retropharyngeal
space: evaluation of normal anatomy and diseases with CT and MR imaging. Radiology 1990;174:59–64.
95. Davis WL, Smoker WR, Harnsberger HR. The normal and diseased infrahyoid retropharyngeal, danger, and prevertebral spaces. Semin Ultrasound
CT MR 1991;12:241–256.
96. Hollinshead W. Anatomy for surgeons: volume 1—the head and neck.
New York: Harper and Row; 1968.
97. Parker GD, Harnsberger HR, Smoker WR. The anterior and posterior cervical spaces. Semin Ultrasound CT MR 1991;12:257–273.
98. Som PM, Curtin HD, Mancuso AA. An imaging-based classification for
the cervical nodes designed as an adjunct to recent clinically based nodal
classifications. Arch Otolaryngol Head Neck Surg 1999;125:388–396.
99. Greene F, Page D, Fleming I, et al, editors. AJCC cancer staging handbook/American Joint Committee on cancer. 6th ed. Philadelphia, PA: Lippincott Raven Publishers; 2002.
100. Robbins KT, Shaha AR, Medina JE, et al. Consensus statement on the
classification and terminology of neck dissection. Arch Otolaryngol Head
Neck Surg 2008;134:536–538.