Anatomy of Face and Neck

by
Prem Nikomchaiprasert

อาจารย์ ทปี่ รึกษา : อ.ทำนุ อาจสมรรถ

 Nervous system of
face & neck
 Trigeminal n. (CN 5)
 Facial n. (CN 7)
 Accessory n. (CN 11)
 Hypoglossal n. (CN 12)
 Cervical plexus
 Autonomic nervous system

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 Trigeminal n. (CN5)
V1. Opthalmic n. :
superior orbital fissure
sensory n.
V2. Maxillary n. :
foramen rotundum
sensory n.
V3. Mandibular n. :
foramen ovale
mixed n. (motor +
sensory
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components)
3
 Trigeminal n. (CN5)
V1. Opthalmic n. : sensory n.
 Frontal n.
 Supraorbital n. : scalp, upper eyelid
 Supratrochlear n. : forehead, upper
eyelid
 Lacrimal n. : sphenopalatine gg.
 Nasociliary n. :
 Long ciliary n. : eyeball, upper
eyelid
 Communicating br.: Ciliary gg.
 Posterior ethmoidal n. :
spenoid/ethmoid sinus
 Infratrochlear n. : lacrimal
apparatus, nasion
 Anterior ethmoidal n. :
 Internal nasal br. Nasal cavity,
ethmoidal aircelsl
 External nasal br. : dorsum/ tip of
nose
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 Trigeminal n. (CN5)
V2. Maxillary n. : sensory n.
 Meningeal n. : dura mater
 Pterygopalatine n. :
sphenopalatine gg.
 Zygomatic n. :
 Zygomaticotemporal n. :
(zygomaticotemporal foramen)
: temporal area
 Zygomaticofacial n. :
(zygomaticofacial for.) : cheek
 Posterior alveolar n.:
maxillary sinus, upper molar
 Infraorbital n. : upper molar,
lower eyelid, side of nose,
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upper lip 5
 Trigeminal n. (CN5)
V3. Mandibular n. : Mixed n.
 Branch of Trunk.
 Meningeal br. : dura mater
 Medial terygoid n. : medial
pterygoid m., tensor tympani
m., tensor veli palatini m.
 Anterior division br. :
 Masseteric n. : masseter m.
 Ant. Deep temporal n. :
temporal m.
 Post. Deep temporal n. :
temporal m.
 Lateral pterygoid n. : lat.
Ptergoid m.
 Buccal n. : skin of buccal area,
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buccal mucosa
 Trigeminal n. (CN5)
V3. Mandibular n. : Mixed n.
 Posterior division br. :
 Auriculotemporal n. :
scalp, skin of preauricular
& temporal area, otic
ganglion
 Lingual n. : somatic
sensation ant. 2/3 tongue,
submandibular gg. (chorda
tympani), taste buds ant
2/3 (chorda tympani)
 Inferior alveolar n.
 Dental br. : inferior alveolar
 Mental n. : chin
 Mylohyoid n. : mylohyoid m.,
ant. belly of digastric m.
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* Retracting submandibular gland to posteroinferior direction :
lingual n., wharton’s duct, hypoglossal n.

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 Facial n. (CN7)

 Supranuclear segment : Cortex (precentral gyri)

 Nuclear segment : facial nucleus, superior
salivatory (pons)
 Cerebellopontine angle : CN 7 + CN 8
 Internal auditory canal : facial n., nervus interme
dius, CN8, internal auditory a.
 Labyrinthine segment : แคบที่สุด

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 Facial n. (CN7)
 Geniculate ganglion :
1
2
greater superficial petrosal 3
n., lesser superficial 4
petrosal n.
 Tympanic segment :
1
nerve to stapedius m. 2
3
 Mastoid segment : chorda t4
ympani n.
 Extracranial segment : post
auricular n., nerve to poster
ior of digastric m., pes anse
rinus 18/8/49 10
 Facial n. (CN7)
 Facial n. : Facial
expression
 Temporal br. : m. เหนือ
zygoma
 Zygomatic br. : กล้ ามเนือ้
บริ เวณ infraorbital
 Buccal br. : buccinator
m., upper lip
 Marginal mandibular
br. : lower lip,
 Cervical br. :
plastysma
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 pes anserinus
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 Stylomastoid
foramen
->tympanomastoid
fis. (lateral surface o
f tympanic bone) .

•Facial n. is usually
located ~1-1.5 cm Tragal pointer

deep and inferior to Facial n.

the tragal pointer Digastric m.

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 Parotid Salivary Gland
 Parotid gland : between
zygomatic arch, ramus
of mandible, masseter
m., mastoid, styloid
process
 Duct : Stensen's
duct :~ 1.5 cm below
zygomatic arch, along
transverse facial a.,
buccal br. (CN VII)
crosses masseter,
pierces buccinator,
opening 2nd molar

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 Parotid Salivary Gland
 In gland : Facial n.
(cervicofacial,
temporofacial),
retromandibular v.,
external carotid a.
maxillary a., superficial
temporal a. , deep parotid
LN
 Surrounded : parotid
fascia (superficial layer of
deep 18/8/49
fascia)
15
 Frey syndrome
(Gustatory sweating)
denervated postganglionic
parasympathetic fibers
growing and innervating
the sweat gland after
removal of the parotid
 Facial n. injury
 Direct anastomosis
 Interposition graft
 Hypoglossal-facial nerve
anastomosis

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 Accessory n. (CN.11)
 Nucleus : nucleus
ambigus + C1-C5
 Branch
Spinal part : SCM,


trapezius m.
 Accessory part :

join vagus n.
(pharyngeal m.,
larynx, soft palate)
Course : Jugular foramen ->Posterior IJV, run obliquely
inferior/posterior SCM (Erb’s point : posterior border of SCM that
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greater auricular n. turn around)
 Hypoglossal n. (CN.12)
 Nucleus : Hypoglossal
nucleus (medulla)
 Hypoglossal canal
 Distribution : All muscle
of tongue (except
palatoglossus CN10)
 Course : cross
superficial both ICA &
ECA, ~1.5 cm above
carotid bifurcation
CN XII ECA ICA
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 Cervical Plexus
 The cervical nerve
plexus
- Cervical spinal nerve C1-
C4
1. Cutaneous branches
2. Ansa cervicalis (ansa
hypoglossi)
3. Phrenic nerve
4. Communicating branches
5. Muscular branches
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 Cervical Plexus
1. Cutaneous Branches :
sensation of cervical
skin
1. Lesser occipital n.
(C2,3) : auricle,
postauricular area
2. Great auricular n.
(C2,3) : auricle, skin
(mastoid, paroitid area)
3. Transverse cervical n.
(C2,3) : anteroir triangle
4. Supraclavicular n.
(c3,4) : posterior triangle,
manubrium sterni
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 Cervical Plexus
2 Ansa cervicalis (Ansa
hypoglossi) :
• Loop : Superior
Ramus (C1,2) and
Inferior Ramus(C2,3)
• Motor : Group of
infrahyoid m.
[sternohyoid,
sternothyroid,
omohyoid m. ;except :
thyrohyoid m. (C1)]
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 Cervical Plexus
3 Phrenic nerve :
• Origin : ventral
rami C3,4,5
• Tract : anterior
scalenus m. to
thoracic inlet
• Supply : pleura,
pericardium,
diaphragm
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 Cervical Plexus
4 Communicating branches
1. C2,3 and CN XII :
Sternocleidomastoid
2. C3,4 and CN XII :
Trapezius
5 Muscular branches
nerve root C1-C4 :
prevertebral m. (rectus
capitis, longus capitis,
longus coli, scalenes,
levator scapulae
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 Montgomery : 110


Phenic
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n. , cervical plexus : Deep to the fascial carpet 24
The Autonomic Nervous System
1. Sympathetic
2. Parasympathetic

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 Sympathetic nervous system
1. Sympathetic nervous system
Origin : T1-T5
Ganglion
1.1 Superior cervical
sympathetic ganglion
1.2 Middle cervical
sympathetic ganglion
1.3 Inferior cervical
sympathetic ganglion
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 Sympathetic nervous system
1.1 Superior cervical
sympathetic ganglion
Origin : Sympathetic
gg. C1-C4
Site : transverse
process C2

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 Sympathetic nervous system
Branches :
 Communicating br. : CN9, CN 12

 Pharyngeal br. : CN9, CN10 : pharyngeal plexus

 External carotid nerves : perivascular plexuses

supply -->vss. of face, sweat glands of face,

smooth m. of face
 Internal carotid nerves

 Internal carotid plexuses : tympanic plexus, greater

superficial pertrosal n.
 Cavernous plexuses : hypophyseal vvs. ,CN3, CN4,
CN5, dilator palpillae
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 Sympathetic nervous system
1.2 Middle Cervical Sympathetic gg.
Origin : Sympathetic gg. C5-C6
Site : transverse process C6
Branches :
1. Gray rami
communicantes : spinal cord C5-
C6
2. Ansa subclavia : inferior
cervical sympathetic gg.
3. Thyroid branches : thyroid
gland
4. Middle cervical cardiac
nerve : cardiac plexuses

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 Sympathetic nervous system
1.3 Inferior Cervical Sympathetic Ganglion
• Origin : C7-C8
• Site : transverse process C7
• 82% รวมกับ thoracic sympathetic 1st : Cervicothoracic
gg. (Stellate gg.)
• Branches :
1. Gray rami Communicantes : spinal cord C6-T1
2. Ansa subclavia : middle cervical sympathetic gg.
3. Inferior cervical cardiac n. : cardiac plexuses
4. Vertebral plexuses : nerve plexuses (vertebral
a., basilar a., cerebral a., cerebellar a.)
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 Sympathetic nervous system

Note :
• Cervical sympathetic gg. injury :
Horner’s syndrome (ptosis, miosis,
facial anhidrosis)
• Stellate Ganglionectomy :
ลด vasospasm of upper limb artery in
Raynaud’s disease
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 Parasympathetic nervous system
2. Parasympathetic Nervous System
2.1 Ciliary gg. : CN3
: ciliary m.,spincter
pupillae m.
2.2 Sphenopalatine gg. : CN7
: lacrimal gl., nasal
cavity, hard/soft palate
2.3 Submandibular gg. : CN7
: Submandibular gl.,
sublingual gl.
2.4 Otic gg. : CN9
: Parotid gl.
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18/8/49 33
The Lymphatic System
 The Lymphatic System

 The six level of the neck

 Superficial group
 Head & Face
 Neck
 Deep group
 Lymphatic channels
 Right lymphatic duct
 Thoracic duct

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 Cervical Lymph Node Groups
 The six level of the neck
 Level I : Submental and
Submandibular group
 Level II : Upper jugular
group
 Level III : Middle jugular
group
 Level IV : Lower jugular
group
 Level V : posterior triangle
group (supraclavicular node)
 Level VI : Anterior
compartment group
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18/8/49 37
 The six level of the neck
 Level IA
 Boundaries

Superior : Symphysis o
f mandible
Inferior : body of hyoid
Medial/Lateral : Anterior
bellies of bilateral diga
stric m.

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 The six level of the neck

 Level IA
 LN : Submental nodes
 Afferent :FOM, ant.
tongue, anterior
mandibular alveolar
ridge, lower lip
 Efferent : Level
IB,II,III
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 The six level of the neck
 Level IB
 Boundaries

Superior : Body of
mandible
Inferior : Posterior belly
of digastric muscle
Medial : Anterior belly of
digastric m.
Lateral : stylohyoid m.

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 The six level of the neck
 Level IB
 LN : Submandibular LN
 Afferent : oral cavity,
ant. nasal cavity,
midface, submandibular
gland
 Efferent : Level II,III

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 The six level of the neck
 Level II
 Boundaries IIA

Superior : Skull base

Inferior : Horizontal
plane defined by inferi
or body of hyoid bone
Medial : Stylohyoid m.
Lateral : Accessory n.

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 The six level of the neck
 Boundaries IIB
Superior : Skull base
Medial : Accessory n.
Lateral : lateral border
of SCM

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 The six level of the neck
 LN Level IIA & IIB: upper
jugular group,
 Afferent Level IIA & IIB :
Oral cavity, base of tongue,
nasal cavity, nasopharynx,
oropharynx, hypopharynx,
larynx, parotid gland
 Efferent Level IIA & IIB :
Level III, IV

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 The six level of the neck
 Level III
 Boundaries
Superior : Horizontal plane defi
ned by inferior border of hyoi
d
Inferior : Horizontal plane defin
ed by inferior border of cricoi
d cartilage
Medial : Lateral border of
sternohyoid m.
Lateral : lateral border of SCM

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 The six level of the neck
 Level III
 LN :Middle jugular group
 Afferent : Oral cavity,
nasopharynx, oropharynx,
hypopharynx, larynx
 Efferent : Level IV

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 The six level of the neck
 Level IV
 Boundaries

Superior : Horizontal plane

defined by inferior border
of cricoid cartilage
Inferior : Clavicle
Medial : lateral border of
sternohyoid m.
Lateral : lateral border of S
CM

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 The six level of the neck
 Level IV
 LN : Lower jugular group,
inferior deep cervical LN
 Afferent : Hypopharynx,
thyroid gland, cervical
esophagus, larynx
 Efferent : jugular
lymphatic trunk

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 The six level of the neck
 Level VA
 Boundaries

Inferior : Horizontal plane de

fined by lower border of cri
coid cartilage
Medial : Post. border of SCM
Lateral : Ant. border of
trapezius m.
 LN : accessory chain

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 The six level of the neck
 Level VB
 Boundaries
Superior : Horizontal plane defin
ed by lower border of cricoid
cartilage
Inferior : Clavicle
Medial : post. border of SCM
Lateral : ant. border of trapezius
m.
 LN : transverse cervical chain,

supraclavicular nodes

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 The six level of the neck
 Afferent :Level VA & VB :
Nasopharynx, oropharynx
cutaneous of posterior scalp &
neck, aerodigestive tract
(Supraclavicular nodes )
 Efferent :Level VA & VB : Level I
V, jugular lymphatic trunk, Right
lymphatic duct, thoracic duct (Lt)

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 The six level of the neck
 Level VI
 Boundaries

Superior : Hyoid bone

Inferior : Suprasterna
l notch
Lateral : Common
carotid a.
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 The six level of the neck
 Level VI
 LN : pre/para tracheal
nodes, precricoid (Delphia
n) node, perithyroidal node
s and nodes along RLN
 Afferent : Thyroid gland,
glottic &subglottic larynx,
pyriform sinus, cervical
esophagus
 Efferent : Level II, III, IV

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Neck Dissection
 Classification
1. Radical neck dissection
2. Modified radical neck dissection
3. Selective neck dissection
4. Extended neck dissection

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 Neck Dissection
Radical Neck Disse
ction Procedure r
emoval :
Ipsilateral
cervical lymph
node groups I-V,
spinal accessory
n., IJV, SCM
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 Neck dissection
 Modified Radical ND
 Level I-V LN group

 Preservation of one
cumming
2627B
or more :
 Spinal accessory n.
 Internal jugular v.

 SCM

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 Neck dissection
 Selective Neck Dissection
 En bloc removal one or more LN groups that are risk
for harboring metastatic cancer
 Extended Neck Dissection
 Any of node dissection classification with remove
either LN, vascular, neural, muscular structure
( retropharyngeal LN, hypoglossal n., levator
scapulae m., carotid a.)

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 Neck dissection
Oral cavity cancer :
 Supraomohyoid neck
dissection (SOHND)
 SND (Level I-III) (+ Cumming
level IV in tongue 2628 116-9
cancer)
; Nodal metas I-III : SND
(I-IV)
; N2c : Contralateral ND

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 Neck dissection
CA oropharynx, hypopha
rynx and larynx :
 Lateral neck dissection :
SND (Level II-IV)
; Cancer involving 116-12
pharyngeal wall : SND (II-I
V, retropharyngeal nodes)
; Cancer extendind below the
glottis : SND (II-IV and VI)

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 Neck dissection
 CA posterior scalp
and upper neck :
 Posterolateral neck
dissection : SND(II-V, p 116-14
ostauricular and subocc
ipital )
 preauricular, ant.
Scalp, temporal region :
SND (parotid and facial
nodes, level IA, IB, II a
nd III)
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 Neck dissection
 Midline structures of
anterior lower neck
 CA thyroid, advanced
glottic cancer, subglottic l
arynx cancer, advanced p
yriform sinus cancer, cervi
116-15
cal esophageal/tracheal c
ancer
 Anterior neck dissection or
central compartment
dissection
 SND (level VI)
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 Neck dissection
 Midline structures of
anterior lower neck
; Metas below 116-16
suprasternal notch :
SND (IV, superior
mediastinal nodes)
; CA Thyroid cancer
with nodal metas Lev
el V : SND (VI and II-
V)
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 The Lymphatic System
 Superficial group
 Head & Face
 Neck

 Deep group
 Lymphatic channels
 Right lymphatic duct
 Thoracic duct

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 The Lymphatic System
 Superficial
group
 Face & Head
– Occipital nodes
– Retroauricular
nodes
– Anterior
auricular nodes
– Superficial
parotid nodes
– Facial nodes
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 The Lymphatic System
 Superficial
group
 Neck

 Submental nodes
 Submandibular
nodes
 External Jugular
nodes
 Anterior jugular
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 The Lymphatic System
 Deep group
– Accessory Chain
– Transverse
Cervical chain
– Juxtavisceral
Nodes
– Deep cervical
Nodes
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 The Lymphatic System
Deep group
Juxtavisceral Nodes
 Infrahyoid group : thyrohyoid membrane
 Prelaryngeal group : cricothyroid ligament
 Pretracheal group : along inferior thyroid artery
 Paratracheal group :along recurrent laryngeal
n.

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 The Lymphatic System
Deep group
4. Deep Cervical Nodes
4.1 Superior Deep
Cervical Nodes
 Retropharyngeal
Nodes
 Deep parotids Nodes
 Jugulo-digastric
Node
 Jugulo-omohyoid
Node
4.2 Inferior Deep
Cervical Nodes
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 Lymphatic Channels
 Right Lymphatic Duct
 Origin :
• Jugular lymphatic trunk (Rt) (inferior deep cervical LN,
Transverse cervical chain)
• Subclavian lymphatic trunk (Rt)
• Bronchomediastinal lymphatic trunk (Rt)
 Distal End : Right Subclavian v. หรื อ รอยต่ อระหว่ าง
Right Subclavian v. กับ Right Internal Jugular v.
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 Lymphatic Channels
2. Thoracic Duct
Origin :
 Lumbar lymphatic trunk
(Rt&Lt)
 Intestinal lymphatic trunk
 Jugular lymphatic trunk
(Lt), transvercervical
lymphatic trunk (Lt),
subclavian lymphatic trunk
(Lt)
Distal End : รอยต่ อระหว่ าง Left
Subclavian v. กับ Left
Internal
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Tissue plane and space
of
face & neck
Cervical fascia
1. Superficial cervical fascia
2. Deep cervical fascia
- Superficial layer
- Middle layer
- Deep layer

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 Superficial cervical
fascia
• deep to dermis

• ensheathes platysma ,m. of

facial expression
• extend from epicranium to
thorax & axilla
• SMAS is part of superficial
cervical fascia
Boundaries(SCF)
• superior : Galea , frontalis
• inferior : platysma

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 Superficial cervical fascia
Superficial musculoaponeurosis
(SMAS)
 Fibromuscular fascia
 Invests the muscles of facial
expression
Boundary
Superior zygomatic arch
Inferior platysma
Posterior SCM
Anterior orbicularis oris
Melolabial crease,upper lip
Ant sup orbicularis oculi
zygomatic major&minor
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 Superficial cervical fascia
Superficial
musculoaponeurosis
(SMAS)
 Branch of CN VII deep to
SMAS
 Lower cheek br CN VII deep
to masseteric fascia
 Potential space between SMAS
& masseteric fascia(avascular
plane) : safely dissect
 Important to Rhitidectomy
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 SMAS FACE LIFT

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 Superficial cervical fascia
Superficial musculoaponeurosis
(SMAS)
 Temporal br.:
- most superficial br,exist superior
parotid gl crossed junction ant 1/3
& post 2/3 zygomatic arch
- Dissect: forhead lift+face lift
 Zygomatic br :
- lie drawn targusmalar eminence
- injury  mild synkinesis lower eye
lid

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 Superficial cervical fascia
Superficial musculoaponeurosis
(SMAS)
 Buccal br :
- exist ant parotid,on to surface
massester m.deep to fascia pass
buccal fat
- injury sagging upper lip
 Mandibular br:

- exist inf parotid, extened along

platysma
- 1-2 cm below body mandible ant
to facial a cross mandible,N is on
inf mandible
- Injury : liposuction
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 Superficial cervical fascia
 Space between superficial cervical
fascia and superficial layer of deep
cervical fascia contains :
 M. : platysma m.,
 N. : great auricular n
 Vessel : ant&ext.jugular v
 Superficial lymphatic
; infection of this space : I&D

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 Superficial layer of
the deep cervical fascia
Rule of two
- envelopes 2 m : trapezius,
SCM
; masticator m. (masseter m.,
pterygoid m., tempolaris m.), ant.
Belly of digastric, mylohyoid m.
- envelopes 2 glands :
submandibular,parotid
- form 2 spaces :space of
posterior triangle,suprasternal
space of BURN

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 Superficial layer of
the deep cervical fascia
Superiorly
 Mastoid processes of
temporal bones
 Mandible
1. Internal layer:cover

pterygoid mskull
base
2. External layer:cover

masseter m., zygoma

tic arches
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 Superficial layer of
the deep cervical fascia
 Inferior
 Manubrium
 Clavicles
 Acromion
 Posterior
 Spinous processes of cervical
vertebrae and nuchal ligamen
t
 Superior nuchal line o
f occipital bone
 Spread anterolatteral
 Anterior
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 Superficial Layer of
the Deep Cervical Fascia

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 Middle layer of the deep
cervical fascia
Middle layer (DCF)
 Muscular division
 Viceral division
Muscular division
 Surrounds infrahyoid

(strap) muscles: Sternohy

oid, Sternothyroid, Omohy
oid, Thyrohyoid
 Superior: hyoid,thyroid

 Inferior: clavicle,sternum

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 Middle layer of the deep
cervical fascia
Visceral division
 Envelopes : thyroid,
trachea, esophagus
 Envelopes : pharyngeal
constrictor & buccinator
bucco-pharyngeal fascia
& form ant.wall
retropharyngeal space
 Buccopharyngeal fascia
form midline raphe in
posterior midline adhere to
alar & fuse~ T2cumming*
18/8/49 87
 Middle layer of the deep
cervical fascia
Visceral division
 Posterosuperior:base of Muscular fascia

skull
 Anterosuperior:thyroid

cartilage & hyoid bone

 Inferior:pericardium

 Laterally both devision

contribute carotid sheath

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 Middle Layer of
the Deep Cervical Fascia

18/8/49 89
 Deep layer of
the deep cervical fascia
1. Prevertrebral division
2. Alar division
1. Prevertebral division
 Anterior: adhere

vertebral body,extend
skull base down length
spine
 Posterior:around

scalene m,vertrebral m
 Envelops vertrebral vv,

brachial plexus,phrenic
n, subclavian
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vv,axillary
90
sheath
 Deep layer of
the deep cervical fascia
Alar division Alar
 Between : middle layer division

& prevertrebral fascia

 Posterior wall of

retropharyngeal space
 Extendes : base of skull

to level of T2 (fuses
with visceral fascia)

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 Deep Layer of
Deep Cervical Fascia

18/8/49 92
 Space of neck
Suprahyoid space Infrahyoid space
 Submandibular space  Suprasternal space

 Parapharyngeal space  Anterior visceral space

 Masticator space  Posterior cervical space

 Parotid space

 Peritonsillar space Space involving entire

length of neck
 Carotid space

 Retropharyngeal space

 Danger space

 Prevertebral space

18/8/49 93
 Space of neck
Suprahyoid space
 Submandibular space
 Parapharyngeal space
 Masticator space
 Parotid space
 Peritonsillar space

18/8/49 94
 Submandibular space

Mylohyoid devide
submandibular space
- Sublingual space
(supramylohyoid)
- Submaxillary space
(inframylohyoid)
Ant.belly digastric devide
Submaxillary space
- medial: submental space
- lateral : submaxillary space

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 Submandibular space
Sublingual space
Boundary :
Superior : floor of mouth
Anterior&Lateral : mandible
Posterior : intrinsic muscle
of base of tongue
Inferior: mylohyoid
Component :
1. Anterior extension of hyoglossus m.

2. Lingual nerve, CN 9, CN12

3. Lingual artery and vein

4. Sublingual gland and duct

5. Deep portion of submandibular gl

6. Wharton’s
18/8/49 duct 96
 Submandibular space
Submaxillary space
Boundary :
Superior mylohyoid
Anterior SLDF
Inferior hyoid bone
Posterior posterior digastric
Component :
1. Anterior belly of digastric muscle

2. Superficial portion of submandibular

gland
3. Submental and submandibular LN

4. Facial artery and vein

5. Inferior loop of CN XII

6. Fat

18/8/49 97
 Submandibular space
 Sublingual continue submandibular via the posterior
margin of the mylohyoid muscle
 Source infection: Odontogenic, oral trauma,
submaxillary or sublingual sialadenitis, or abscess of
mandibular teeth 1st molarsublingual
2nd,3rd molarsubmandibular
 Clinical:
Ludwig angina
drooling,pain, dysphagia,
submandibular mass, and
dyspnea or airway
compromise

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 Parapharyngeal space

Boundary :
superior base of skull
inferior hyoid bone
anterior pterygomandibular
raphe

posterior prevertebral fascia

medial superior constrictor
Lateral parotid, mandible,
18/8/49
lateral pterygoid 99
 Parapharyngeal space
 Prestyloid
 Muscular compartment
 Medial—tonsillar fossa
 Lateral—medial pterygoid
 Contains fat, connective
tissue, nodes
 Poststyloid
 Neurovascular
compartment
 Carotid sheath
 Cranial nerves IX, X, XI, XII
 Sympathetic chain
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 Parapharyngeal space
= Lat. Pharngeal ,pharyngomaxillary ,peripharyngeal space
 Infection in prestyloid:

neck pain,odynophagia,trismus swelling below jaw

angle,displace pharyngeal wall
 Infection in poststyloid:

- sepsis,little trismus,Horner’s syn.,

paresis CN IX to XII

- internal jugular thrombosis

(Lemierre’s syn.),
- carotid rupture

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 Masticator space
Masticator space : 3 space*cumming
 masseteric
 temporal
 Ptrygoid
Component :
1. Muscles of mastication : medial and
lateral pterygoids, masseter muscle
2. Tendon of insertion of temporalis
muscle
3. Branches of CN V3 (Inferior alveolar
nerve)
4. Branches of internal maxillary artery
5. The ramus and posterior body of
mandible
• Clinical : extreme trismus,
edema&tender post. ramus mandible
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 Masticator space
Temporal space
 Superficial temporal space :
Medially temporalis m
Laterally superficial temporalis
fascia
 Deep temporal space :
Medially periosteum of temporal
bone
Laterally temporalis muscle
 Infratemporal space
Medially lat.plate pterygoid
Laterally deep temporal space
superior skull base
18/8/49 103
 Masticator space

Temporal space
 Component :
- internal maxillary artery
- mandibular vessels and
nerves
 Clinical : pain temporal m
,trismus ,occasional
deviation of jaw to affect
side

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 Masticator space
Masseteric space
Boundary :
Lateral masseter m
Medial mandible
Source : spread from
buccal space infection
Clinical : trismus,postero
–inferior face swelling
18/8/49 105
 Masticator space
Pterygomandibular
space
Boundary
 Sup Lateral pterygoid m

 Inf Pterygomasseteric
sling
 Ant Pterygomandibular

raphae
 Post Parotid

 Med Medial pterygoid

 Lat
18/8/49Medial ramus 106
 Masticator space
Pterygomandibular
space
 Infection would lead to
trismus,on swelling
 Infection most spread
from sublingual
submandibular space
 Commonly would lead to
lateral pharyngeal space i
nvolvement.

3 space
(temporal,masseteric,ptery
gomandibuar sp)
communicate freely
18/8/49 107
 Parotid Space

 Bounded by
superficial layer of
deep cervical fascia
 Posterior to
masticator and lateral
to PPS
 Extend from EAC –>
inferior edge of angle
of mandible

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 Parotid space
Component :
1. Parotid gland and proximal duct

2. Facial nerve

3. retromandibular vein, Br. of

external carotid and internal
maxillary artery
4. Intraparotid LN
• Fascia not cover upper inner

surface parotid gl  communicate

PPS
• Source infection : parotid

• Clinical :swelling angle of jaw

without trismus
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 Peritonsillar Space

Boundary :
Medially capsule of
tonsil
Laterally superior
constrictor
Ant&Post tonsillar pillars
Component :

- loose connective
tissue
18/8/49 110
 Peritonsillar space

 Source: tonsil,pharynx
 Clinical: dysphagia

muffle voice,trismus
tonsil displace,uvular
deviate across midline
to opposite side
 Infect involve

juxtrapharyngeal space
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 Space of neck
Infrahyoid space
 Suprasternal space

 Anterior visceral

space
 Posterior cervical

space

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 Suprasternal space

 Suprasternal space of
BURN
 SLDF split attach to
anterior and posterior
Suprasternal
surface of manubrium sp.
 Component : 2 head of
SCM, lower end of
ant.jugular vein, the
jugular arch, and LN
 Closed space
18/8/49 113
 Anterior Visceral Space
Boundary :
Superior hyoid bone
Inferior mediastinum
Anterior SLDF
Posterior RPS,prevertebral
Lateral PPS,carotid fascia
Component :
Pharynx,larynx,esophagus,
trachea,thyroid&parathyroid gl
RLN, LN
18/8/49 114
 Anterior Visceral Space

 “Pretracheal space”
 Source :
most infectionperforate by instrument
FB ,external trauma
 Clinical :
Dysphagia,hoarseness,dyspnea,UAO

18/8/49 115
 Posterior cervical space

 Boundary :
Floor deep layer of DCF
Superior superficial layer of DCF
Inferior omohyoid
Extend from skull base clavicle
 Posterior triangle portion

 posterolateral to carotid space

between SCM and trapezius

 Component : fat, spinal
accessory n., spinal accessory
chain of deep cervical nodes
18/8/49 116
 Space of neck
Space involving entire
length of neck
 Carotid space
 Retropharyngeal space
 Danger space
 Prevertebral space

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 Carotid space
Boundary :
Superior skull base
Inferior aortic arch
Anterior SCM
Posterior prevertebral space
Medial visceral space
Lateral SCM Carotid space
Component
- carotid a
- IJV
- CN X
18/8/49 118
 Carotid space

 Mosher in 1929 “ Lincoln Highway ”

 Source: most infected PPScarotid space
 Clinical:tender&swelling SCM,torticollis,vocal cord
paralysis
 Complication:IJV thrombosis (Lemierre
syndrome) ,carotid rupture

18/8/49 119
 Retropharyngeal Space

Boundary :
 Superior skull base
 Inferior superior
mediastinum,
~T2cumming
 Anterior pharynx &
esophagus
 Posterior alar fascia

 Lateral carotid sheath

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 Retropharyngeal space

 Component: LN,CNT
 Source: infected
nose,NP,adenoid,PNS (most
in child)
in adult :instrument, FB
,trauma
 Clincal:unilat midline
abscess pain, dysphagia
,nuchal rigidity,air way
compromise

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 Danger space
Boundary :
Superior skull base
Inferior diaphragm
Anterior alar fascia
Posterior prevertebral
fascia
Lateral transverse
process of vertebrae
Component : CNT

18/8/49 122
 Danger space

 Source: PPS,retropharyngeal,prevertrebral space

 Clinical:similar retropharyngeal space infecion
 Complication:mediastinitis

18/8/49 123
 Prevertrebral space

Boundary :
Superior skull base
Inferior coccyx
Anterior prevertebral fascia
Posterior vertebral bodies
Lateral transverse process
of vertebrae
 Component

1. Dense areolar tissue forming a

very 18/8/49
compact space * LEE 124
 Prevertrebral space
 Source: pyogenic/TB spine
(Pott’s abscess) , trauma
 Clinical : midline abscess
,vertrebral osteomyelitis ,
spinal instability,similar
retropharyngeal space
infecion

18/8/49 125
 Imaging
 Lateral neck plain film
 Screening exam
 Normal:
 7mm at C-2
 14mm at C-6 for kids
 22mm at C-6 for adults
 Technique dependent
 Extension
 Inspiration
 Sensitivity 83%,
compared to CT 100%

18/8/49 126
Surgery
 External drainage
 Landmarks
 Tip of greater horn of
hyoid
 Cricoid cartilage
 Styloid process
 SCM

 Transoral drainage

 Needle aspiration

18/8/49 127
 Network of infectious
extension
Submandibular masticater temporal

Peritonsillar PPS parotid

Carotid danger RPS

prevertebral

Ant.cervical mediastinum

18/8/49 128
 Thank you
References :
 Byron J. Bailey et al, Head&Neck surgery-
otolaryngology, 3rdedition 2001
 Charles W. Cummings et al, Cummings
Otolaryngology- Head&Neck surgery,4th edition 2005
 Jeffrey Buyten, MD Francis B. Quinn, MD UTMB
Department of Otolaryngology, Deep Neck Space
Infections 2005
 มีชยั ศรี ใส, ธันวา ตันสถิต, ภาคภูมิ สุ ปิยพันธุ์, บุญเที่ยง ศีติสาร มหการวิภาคประยุกต์
เล่มที่ 2 พิมพ์ครั้งที่ 3 เยียร์บุค๊ พับลิชเชอร์ 2541
 เอกสารประกอบการสอน tissue plane space in H&N , พ.ศิริเพ็ญ
 เอกสารประกอบการสอน tissue plane space in H&N , พ.พรเทพ
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18/8/49 130
18/8/49 131
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Important Landmarks
 Important Landmarks
 Submental Triangle
 Anterior Triangle
 Submandibular Triangle
 Carotid Triangle
 Muscular Triangle
 Posterior Triangle
 Occipital Triangle
 Supraclavicular
(Omoclavicular) Triangle
18/8/49 134
 Important Landmarks
 Submental Triangle
 Boundaries : Hyoid,
Lt/Rt anterior belly
digastric m.
 Contain :

 Submental vss.
 Submental LN

 Mylohyoid m.

18/8/49 135
 Important Landmarks
Anterior Triangle
 Boundaries : Midline of

neck , lower border of

mandible, anterior border
of sternocleidomastoid
m.
 Contain
 Submandible triangle
 Carotid Triangle
 Muscular Triangle
18/8/49 136
 Important Landmarks
 Submandibular
Triangle
 Boundaries :
 Anterior belly of

digastric m.
 Posterior belly

of digastric m.
 Lower border of

mandible
18/8/49 137
 Important Landmarks

 Submandibular Triangle
 Contain
 Submandibular gland and Wharton’s duct
 Submandibular LN

 Lingual n., CN12, submandibular gg

 Lingual a., facial a., anterior facial v.

18/8/49 138
 Important Landmarks
 Carotid Triangle
 Boundaries :
 Posterior belly of
digastric m.
 Superior belly of

omohyoid m.
 Anterior border of

sternocleidomastoi
d m.
18/8/49 139
 Important Landmarks
 Carotid Triangle
 Contain
 Common carotid a., carotid sinus, internal carotid
a., external carotid a. ( and br. : superior thyroid a.,
ascending pharyngeal a., lingual a., facial a.)
 Internal jugular v., ( and br. : superior thyroid v.,

lingual v., facial v. )

 Deep cervical LN

 CN10, CN11, CN12, Ansa hypoglossi, cervical

sympatheitic
18/8/49
trunk 140
 Important Landmarks
 Muscular Triangle
 Boundaries :
 Midline

 Superior belly of

omohyoid m.
 Anterior border

of
sternocleidomast
oid m.
18/8/49 141
 Important Landmarks
 Muscular Triangle
 Contain
 Thyroid gl, parathyroid gl, larynx, trachea, esophagus

 Infrahyoid m., infrahyoid fascia

 Superior/inferior thyroid a.,

 Superior/middle/inferior thyroid v., anterior jugular v.

 Internl laryngeal n., external laryngeal n., recurrent

laryngeal n.
 Infrahyoid LN, paratracheal LN., anterior jugular LN,

right lymphatic duct, thoracic duct

18/8/49 142
 Important Landmarks
 Posterior Triangle
 Boundaries : posterior

border of
sternocleidomastoid,
anterior border of
trapezius m., middle(1/3)
part of clavicle
 Contain
 Occipital Triangle
 Supraclavicular
(Omoclavicular) Triangle
18/8/49 143
 Important Landmarks
 Ocipital Triangle
 Boundaries :
 Posterior border of
sternocleidomastoid
 Anterior border of

trapezius m.
 Inferior belly of

omohyoid m.

18/8/49 144
 Important Landmarks
 Ocipital Triangle
 Contain
 CN11, lesser occipital n., great auricular n., dorsal
scapular n., transverse cervical n., supraclavicular n.
 Transverse cervical a.

 Transverse cervical v., external jugular v.

 Accessory cervical chain, transverse cervical chain,

external jugular LN

18/8/49 145
 Important Landmarks
 Supraclavicular
Triangle
 Boundaries :
 Posterior border of
sternocleidomastoid
 Inferior belly of

omohyoid m.
 Middle(1/3) part of

clavicle
18/8/49 146
 Important Landmarks
 Supraclavicular Triangle
 Contain
 Subclavian a., thyrocervical trunk, vetebral a.,
internal thoracic a., costocervical trunk,
transverse cervical a., suprascapular a.
 Subclavian v., external jugular v.

 Brachial plexus

 Supraclavicular nodes (node of Virchow)

18/8/49 147