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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 Anat-
omy, 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 term ‘‘spaces’’ is inappropriate. A modified nomenclature underpinned
fascia and its associated compartments is essential for differential diag- by evidence-based anatomic and radiologic findings is proposed. This
nosis, predicting the spread of disease, and surgical management. The should not only enhance our understanding of cervical anatomy but also
purpose of this detailed review is to summarize the anatomic, clinical, facilitate clearer interdisciplinary communication. V C 2014 Wiley
and radiological literature to determine what is known about the Periodicals, Inc. Head Neck 36: 1058–1068, 2014
arrangement of cervical fascia and to highlight controversies and con-
sensus. The current terminology used to describe cervical fascia and
compartments is replete with confusing synonyms and inconsistencies, KEY WORDS: head, neck, fascia, anatomy, terminology
creating important interdisciplinary differences in understanding. The

INTRODUCTION A contributing factor is the variability of what is meant by


‘‘fascia.’’ Definitions usually refer to an organized arrange-
Historically, anatomic and clinical studies have described
ment of connective tissue that can be discerned macroscopi-
cervical fascia in the context of the spread of infection and
cally.6–9 This is often limited to the fibrous connective tissue
surgical management of disease.1,2 These provided the
that forms sheets or sheaths around structures,7,10 but the
foundation for modern radiology texts that focus on the
International Fascia Research Congress recently broadly
contents of named ‘‘spaces,’’ which is essential in differen-
redefined fascia as ‘‘the soft tissue component of the connec-
tial diagnosis.3,4 However, as surgical technology advances,
tive tissue system that permeates the human body’’ including
a more precise understanding of fascial arrangements and
‘‘all fibrous connective tissues, aponeuroses, ligaments, ten-
their variations becomes imperative. For example, endo-
dons, retinaculae, joint capsules, organ and vessel tunics, the
scopic and robotic surgery offer access to previously inac-
epineurium, the meninges, the periostea, and all the endomy-
cessible areas and provide new approaches to standard
sial and intermuscular fibers of the myofasciae.’’10 The clas-
procedures with reduced morbidity.
sification of fascia is similarly variable with groupings based
A recent review of recommended texts for radiology
on developmental origin, function, or appearance.9,11–13 Fas-
and surgery trainees and students of anatomy highlighted
cia can vary between individuals according to mechanical
widespread confusion about both the layers of cervical
stress, age, and disease processes.14–16
fascia and their potential spaces.5 Not only were descrip-
This report reviews historic and modern anatomic, clinical,
tions of fascial arrangements and definitions of spaces
and radiologic studies of head and neck fascia with the pur-
inconsistent and unclear, but the terminology was variable
pose of identifying areas of consensus and controversy. A
and open to misinterpretation. The names used to describe
modified nomenclature that has the potential to encourage
the fascial layers around the parapharyngeal, submandibu-
greater cross-disciplinary understanding of head and neck
lar, and visceral spaces were particularly confusing.
fasciae and its associated compartments is proposed.

METHODS
*Corresponding author: A. K. Guidera, Department of Surgical Sciences, Dune-
An Ovid MEDLINE (1946–July 2012) search was con-
din School of Medicine, PO Box 913, Dunedin 9054, New Zealand. E-mail: ducted using the MeSH terms: ‘‘fascia,’’ ‘‘neck,’’ and
alice_guidera@yahoo.co.uk ‘‘anatomy,’’ ‘‘radiology’’ or ‘‘surgery,’’ and keywords
Contract grant sponsor: This review was completed as part of ongoing research ‘‘deep cervical fascia,’’ ‘‘cervical fascia,’’ ‘‘prevertebral
funded by The Foundation for Surgery Research Scholarship, Royal Australa- fascia,’’ ‘‘pretracheal fascia,’’ ‘‘investing fascia,’’ and
sian College of Surgeons; a Dunedin School of Medicine Clinical Research ‘‘superficial cervical fascia.’’ Further searches were con-
Scholarship, University of Otago; and The Richard Stewart Scholarship awarded
by The Dunedin Basic Medical Sciences Course Trust, Dunedin School of Medi- ducted using the keywords ‘‘masticator space,’’ ‘‘subman-
cine, University of Otago. dibular space,’’ ‘‘retropharyngeal space,’’

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‘‘parapharyngeal space,’’ ‘‘lateral pharyngeal space,’’ ‘‘completely encircling the neck,’’1,17–19,21,24,34 although it
‘‘prevertebral space,’’ ‘‘visceral space,’’ and ‘‘deep neck has been suggested that it is incomplete between the sterno-
space,’’ all limited to ‘‘human.’’ Relevant original cleidomastoid and trapezius muscles.35,36 A simplified
research articles were supplemented by additional referen- ‘‘rule of twos’’ describes the SLDCF as enclosing 2 glands
ces obtained from article reference lists. (submandibular and parotid), 2 muscles (sternocleidomas-
Illustrations were created in Adobe Illustrator (CS5.1) toid and trapezius), and 2 ‘‘spaces’’ (suprasternal space and
from 2 sources: plastinated E12 axial slices (2.5-mm thick- the ‘‘subvaginal’’ space of the posterior triangle).17,19,34
ness) through the head and neck of a 65-year-old female The relationship between the SLDCF and the middle layer
cadaver available through the W.D. Trotter Anatomy of deep cervical fascia (MLDCF) is variously described.
Museum at the University of Otago; and from anonymized Some authors report that they are fused at several sites: at
normal MRIs obtained after institutional ethics committee the hyoid; along the superolateral border of the anterior belly
approval (LRS/11/EXP/013). of omohyoid continuing along its posterior belly into the pos-
terior triangle; where the MLDCF covers the sternothyroid
Layers of cervical fascia and thyrohyoid1; and with the buccopharyngeal fascia.23
For the purposes of this review, discussion is limited to Superior to the hyoid, the SLDCF attaches to the mandi-
fascia that is traditionally described as delineating poten- ble and styloid process, fusing with the sheath around the
tial spaces within the head and neck. The pharyngobasilar digastric, and splitting to enclose the submandibular gland
fascia and fasciae that might otherwise be regarded as a separating it from hyoglossus and the superior constrictor
tendon or ligament are not included. muscle on its deep surface1; a thickening of this layer con-
tributes to the stylomandibular ligament.17,37,38 Superior
Superficial cervical fascia to the mandible, the SLDCF splits into 2 laminae, the
The variable definition of fascia is the root of much of lateral lamina covering the masseter and attaching to the
the confusion surrounding the superficial cervical fascia zygomatic arch1,39 and the medial lamina running on
(SCF). Some authors describe this as a continuous sheet the deep surface of the pterygoid muscles and attaching
of fascia extending from the head and neck to the thorax to the skull base medial to the foramen ovale.1,23,38–41
and axillae,1,2,17 whereas others use the term to indicate a The most cranial extension of the SLDCF is disputed.
layer indistinguishable from,18 or synonymous with,19,20 Some authors refer to the temporal fascia that extends up
the subcutaneous fat. The term ‘‘superficial cervical fas- over the temporalis to attach to the superior temporal
cia’’ has been removed from the current reference source line8,42 as a continuation of the SLDCF,1,23,39,41,43 whereas
on anatomic nomenclature because it no longer represents others limit the superior extent to the zygoma18,34,39,44 or
a standard description.9 In the neck, the SCF contains the extend it into the aponeurotic layer of the scalp.23 There is
platysma and superficial lymph nodes1,18,19,21,22 and is also debate about whether the SLDCF completely invests
loosely arranged to facilitate neck movement. the parotid gland26,29,30 and its relationship to the masse-
Craniad to the mandible, the SCF continues as the fascia teric fascia.1,23,39 This is not a new argument.43 More
that ‘‘invests’’ the muscles of facial expression and occipi- recent studies suggest that the SLDCF is continuous with
tofrontalis in the scalp1,19,23; it is referred to by different the fascia covering the masseter muscle but that the parotid
names as it progresses cranially.24 Interest in this layer was gland lies laterally and is covered with fascia of a different
renewed with the popularization of facelift surgery and the origin, variably described as SCF, innominate fascia,31 or a
definition of the superficial musculoaponeurotic system ‘‘platysmal’’ layer.22,27,29,30
(SMAS).22,25–27 Starting at the vertex, the galea aponeuro-
tica, occipitofrontalis, and orbicularis oculi muscles are in
continuity with the temporoparietal fascia24,28 and, inferior Middle layer of deep cervical fascia. This is described as
to this, the SMAS over the zygomatic arch25,28 (although having muscular and visceral divisions1,2,17,19,34,37,38 or
not all authorities agree on the latter).8 This layer, which simply a visceral part.18,39,44–46
incorporates the muscles of facial expression, is then con- Muscular layer. This term is usually used in conjunction
tinuous with the SCF and platysma in the neck.26,29,30 with ‘‘visceral fascia’’ to describe that portion of the
Beneath the temporoparietal fascia is a layer of loose but MLDCF that ensheaths the strap muscles.17,19,47 Some
vascular connective tissue often called the innominate fas- authors subdivide it into sternohyoid/omohyoid and ster-
cia by plastic surgeons31; this is continuous with the subga- nothyroid/thyrohyoid components,1,47 whereas others refer
leal layer in the scalp but its limits are not well described. to it generally as the ‘‘strap fascia,’’35 or even part of the
The relationship between the SMAS and the SCF is SLDCF.21,34 This layer runs between the bony attach-
contentious: descriptions range from the two being synon- ments of these muscles.
ymous,26,32 related,33 distinct,27 or there being no such
layer as the SMAS as originally defined by Mitz and Visceral layer. This has been used to describe all the compo-
Peyronie.22,25,29 These predominantly histologic studies nents of the MLDCF19 or only that part surrounding the lar-
have also suggested that the SCF (rather than the superfi- ynx, pharynx, trachea, esophagus, and thyroid.1,18 The latter
cial layer of deep cervical fascia) forms the lateral fascial is generally agreed to blend inferiorly with the fibrous pericar-
layer over the parotid.26,29,30 dium1,17–19,34,37,38,44 but there is disagreement as to whether it
extends superiorly only to the level of the hyoid bone34,38,44
Deep cervical fascia or if a posterior continuation reaches the skull base.1,17–19,39,47
Superficial layer of deep cervical fascia. The superficial layer Buccopharyngeal fascia. The prefix ‘‘bucco’’ refers to the
of deep cervical fascia (SLDCF) is usually described as superior extension of this layer that is stated to continue

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TABLE 1. Historical and suggested terms for the cervical fascia.

Layer Other terms Suggested term

SCF Galea aponeurotica, temporoparietal fascia, Subcutaneous tissue


superficial temporal fascia, subcutaneous
tissue, platysmal layer, and
subcutaneous musculoaponeurotic system
DCF
Superficial layer Subaponeurotic layer of galea aponeurotica, Masticator fascia
parotidomasseteric fascia Submandibular fascia
Investing fascia, enveloping layer, general or deep Sternocleidomastoid-trapezius fascia
investing fascia, great cervical sheath, external layer,
and anterior layer29,30
Middle layer Muscular division Strap muscle fascia
Sterno-omohyoid layer
Sternothyroid-thyrohyoid layer
Visceral fascia, pretracheal fascia, prethyroid fascia, Visceral fascia
and buccopharyngeal fascia Pharyngomucosal fascia
Deep layer Prevertebral, perivertebral, and paravertebral Perivertebral fascia (prevertebral
Scalene fascia for anterior part only)
Alar fascia Alar fascia

Abbreviations: SCF, superficial cervical fascia; DCF, deep cervical fascia.

over the buccinator muscle.19 This term has been used to layers of DCF,4,20,39,41,49–52 but offer little explanation as
refer to the whole ‘‘visceral’’ component of the to how this occurs. In their seminal article in 1938, Gro-
MLDCF,1,4,17,39,48 or to a discrete entity that is adherent dinsky and Holyoke1 suggested that the carotid sheath
to the pharynx and either continuous with,1,46 or separate receives contributions from the alar fascia (DLDCF)
from23,34 the MLDCF. throughout its length, from the SLDCF adjacent to the
digastric and sternocleidomastoid muscles, and from the
Pretracheal fascia. This term is rarely used in isolation. With
MLDCF where it covers the sternothyroid. A few authors
the exception of 1 reference restricting the term to that por- offer alternative descriptions stating that the carotid
tion of the MLDCF lying anterior to the trachea,34 ‘‘pretra- sheath is made up of the SLDCF and pretracheal layers
cheal’’ was synonymous with the MLDCF surrounding the of fascia,53 or is independently derived but receives a
larynx, pharynx, trachea, esophagus, and thyroid.1,17,34,44 contribution medially from the alar fascia.45 Older litera-
Other terms in the literature include the ‘‘pharyngomu- ture contains even more diverse statements about the
cosal fascia’’ to describe the purely visceral portion of composition of the carotid sheath.18,37,47,54
the MLDCF45 and the ‘‘viscerovascular system’’ of fascia Histologic studies have found that the carotid sheath is
to describe the fascia surrounding the viscera of the neck always present in its upper third55 and distinct from other
and the carotid sheath.43,47 fascial layers.15 The thickness of the carotid sheath varies
between individuals and at different levels in the neck.15
Deep layer of deep cervical fascia It seems to form a barrier to metastatic disease.56 It is
This is consistently described as encompassing the verte- developmentally distinct from the prevertebral fascia and
bral column and paravertebral muscles, attaching to the is intimately related to the fascia enclosing omohyoid14
transverse and spinous processes of the cervical verte- and the visceral compartment15 in part of its course.
brae.1,2,17,39 As it passes laterally over the scalene muscles,
it forms the floor of the posterior triangle. The term ‘‘pre- Recommendations on cervical fascia
vertebral’’ is used to describe either the complete circum- The terms ‘‘superficial’’, ‘‘middle’’, and ‘‘deep’’ layers
ferential layer of fascia2,45 or just that part covering the of cervical fascia are confusing and should be abandoned
prevertebral muscles anteriorly between the transverse proc- for several reasons. First, the term ‘‘superficial fascia’’ is
esses.1,21,34,37,38 Laterally, it is described as being continu- poorly defined and variably applied.7,9,12,31,57,58 It can
ous with the axillary sheath and the suprapleural membrane refer to the layer of fatty connective tissue immediately
(Sibson’s fascia). Caudally, it is stated to extend to the coc- deep to the dermis,12 or more specifically to a membra-
cyx1,2,17,19 or ‘‘fades away’’ in the thorax.34 nous layer within the fatty subcutaneous tissue.59 Second,
The alar fascia is generally stated to be a division of there is obvious confusion in having a term that contains
the deep layer of deep cervical fascia (DLDCF) spanning more than 1 descriptor (eg, ‘‘superficial’’ and ‘‘deep’’).
between the transverse processes of the cervical vertebrae Third, the ‘‘middle’’ layer is actually anterior to the
anterior to the prevertebral fascia and fusing laterally ‘‘deep’’ layer, which, in places, is relatively superficial.
with the carotid sheath.1,2,17,19,21 Finally, these terms imply distinct fascial layers that are
independent of each other, whereas at some sites they are
Carotid sheath closely associated and even fused.
Modern radiologic and surgical sources frequently Adopting the following terms (Table 1) may reduce
describe the carotid sheath as being composed of all 3 confusion:

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‘‘Superficial fascia’’ should be replaced by ‘‘subcutane- or expanse that is free, available, or unoccupied.’’60 In
ous tissue’’ as recommended in Terminologia Anatomica9; the neck, a ‘‘space’’ may refer to a functional
in many regions, this may contain a readily identifiable unit,2,50,52,53 or anatomic region bounded by fascia,39,61–63
membranous layer and/or cutaneous muscles. Although or a region bounded by bones, muscles, fascia, or skin.23
there is some debate about the existence of SMAS, it With advances in radiology, ‘‘spaces’’ have often been
seems to be a feature of this layer but its relationship to defined by their anatomic contents (eg, blood vessels,
the parotid gland is controversial. lymph nodes, nerves, and viscera) rather than their fascial
Fascia that invests muscle is best described according perimeters, and have tended to become regions containing
to its related functional muscle group. Thus, the mastica- a set of defined structures easily identifiable on cross-
tor fascia covers the muscles of mastication (and therefore sectional imaging.41,53 Most ‘‘spaces’’ in the body are in
includes the temporal, masseteric, and pterygoid fasciae) fact either ‘‘potential spaces’’2,23,64,65 or
19,37,38
and defines the boundaries of the masticator space. The compartments.
strap muscle fascia invests sternohyoid, thyrohyoid, ster- For discussion purposes, ‘‘spaces’’ in the head and
nothyroid, and omohyoid and can be distinguished from neck can be roughly divided into cranial (related to the
both the fascia of the overlying sternocleidomastoid and skull and face) and cervical (related to the cervical spine),
that surrounding the underlying visceral and carotid com- although these distinctions are not absolute.
partments, although they may be adherent in places.1,14
The fascia of the styloid muscles and posterior belly of Cranial fascial ‘‘spaces’’
digastric is often ignored in discussions of the DCF, but The cranial fascial ‘‘spaces’’ include the spaces related
the proposed classification would allow this fascia to be to the parotid gland, muscles of mastication, and the sub-
called the ‘‘styloid fascia.’’ This scheme would also rec- mandibular gland.
ognize the sternocleidomastoid-trapezius fascia as inves-
ting these muscles and bridging the gap anteriorly
between the sternocleidomastoid muscles; until the con- Parotid space. The term ‘‘parotid space’’ is used almost
troversy about whether this fascia bridges the posterior exclusively in the radiologic literature.41,45,66,67 It
triangle is resolved, there is no need to consider revising describes the potential space created by the fascia that
this to separate sternocleidomastoid and trapezius encloses the parotid gland,4,39,41,66,67 although, as noted
fasciae.35,36 previously, the precise fascial arrangement in this area is
The fascia passing between the hyoid and the mandible debatable.22,29 The deep lobe of the parotid gland extends
that splits to encompass the submandibular gland and posteromedial to the mandible and forms a lateral border
forms the floor of the submandibular space would be of the parapharyngeal space. Although anatomic studies
called the ‘‘submandibular fascia’’ (distinct from the cap- suggest that the fascia covering this aspect of the parotid
sule of the submandibular gland). is complete,1 the spread of infection from the parotid to
The terms ‘‘pretracheal’’ and ‘‘buccopharyngeal’’ are the parapharyngeal space noted in the clinical literature
ambiguous and anatomically imprecise and should be indicates that it does not provide a functional barrier.43,67
abandoned. The fascia surrounding the larynx/trachea,
pharynx/esophagus, and thyroid should be designated Masticator space. This was originally defined as a discrete
‘‘visceral fascia.’’ region limited by the masseter, pterygoid, and temporal
The confusion surrounding the extent of the ‘‘DLDCF’’ muscles in continuity with but not including the superficial
seems to be limited to texts.5 In the anatomic literature, and deep temporal spaces. Some anatomic studies have
this layer extends between the transverse processes of the taken the zygomatic arch as the superior extent of this
cervical vertebrae anterior to the prevertebral muscles, is space but agree that there is free communication with the
continuous laterally with the scalene fascia, and extends superficial and deep temporal spaces.1,2,23,43 Other studies
posteriorly to reach the cervical spinous processes. have referred to a single masticator space that also includes
Because this layer surrounds the vertebral column and its the buccal fat pad anterolaterally,68,69 or subdivided the
musculature, the term ‘‘perivertebral fascia’’ would be space into suprazygomatic, retrozygomatic, infratemporal,
more appropriate for fascia lateral and posterior to the and nasopharyngeal regions.4,19,23,39,45,50,61
transverse processes45,52,53 with prevertebral fascia defin-
ing the fascia on the anterior surface of the prevertebral Superficial and deep temporal spaces. The superficial tem-
muscles. The term ‘‘alar fascia’’ can be retained to poral space is the space between the temporal fascia cover-
describe the discrete layer of fascia immediately anterior ing the temporalis and the temporoparietal fascia. The deep
to the prevertebral fascia spanning between the transverse temporal space lies between the temporalis, the periosteum
processes of the cervical vertebrae. of the temporal bone, and the lateral pterygoid muscle.17,43
The carotid sheath surrounds the internal carotid artery, Both spaces freely communicate anteriorly and the deep
internal jugular vein, and lower cranial nerves. It is con- temporal space communicates with the masticator space.
nected to and reinforced by adjacent fascia at different
sites (eg, the alar, visceral, and strap muscle fascia).
Infratemporal space (fossa). To anatomists, this is the post-
maxillary region between the ramus of the mandible later-
Fascial ‘‘spaces’’ and planes ally and the pharyngeal wall medially inferior to the
Defining ‘‘spaces’’ in the head and neck is similarly zygomatic arch.8 Various boundaries delimited by
prone to misinterpretation and confusion. The Oxford muscles and the parotid gland are described in the clinical
English Dictionary defines a space as ‘‘a continuous area literature70–75 with some radiologists choosing to include

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both the masticator and parotid spaces as subdivisions of phragm’’)75,83,84; the tensor veli palatini and its fas-
this fossa.76 cia40,84; the ‘‘stylopharyngeal aponeurosis’’18,19,38,78,85;
and the levator veli palatini and its fascia.86 To com-
Buccal space. Originally described as the space occupied pound the confusion, some authors have added a further
by the buccal fat pad anterior to the masseter muscle,23 it subdivision, namely a third medial compartment (retro-
has often been neglected in discussions of spaces in the pharyngeal)81,87 or a posterior hypoglossal compart-
head and neck. The buccal space is bordered anterolater- ment.88 Some studies have reported free communication
ally by subcutaneous tissue and the zygomaticus major, between these subdivisions,20,38,47,64 whereas others
minor, and risorius muscles,23,41,77 medially by the bucci- have found the converse.18,19,37,88
nator, and posteriorly by the mandible, masseter, and The second controversy centers on whether the para-
pterygoid muscles. Continuity of the buccal fat pad with pharyngeal space is entirely enclosed18,78 or communi-
the temporoparietal fat pad is well described.23,41,45,68,69,77 cates with the parotid, submandibular, and/or
Infection in this region is stated to always involve the retropharyngeal spaces.1,20,37,38,47,63,64 Injection of gelatin
masticator compartment,66 and, although clinical studies into the parapharyngeal space of cadavers has shown free
report early confinement of infection, spread into the communication with the retropharyngeal space1 but no
parotid, temporal, and submandibular spaces occurs with communication in the reverse direction.37
disease progression.61,69
Carotid space. This is bound by the carotid sheath. It is
said to be susceptible to infection from any of the sur-
Submandibular space. This term (and the archaic ‘‘sub-
rounding layers and compartments,17,44,47 but clinical
maxillary space’’) has been used to describe 2 different
studies have found that disease tends to be reasonably
anatomic regions: first, the space inferior to the mylo-
isolated along the course of the sheath.2,19
hyoid 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 Pharyngeal mucosal space. This term has appeared in the
the floor of mouth.1,3,19,43 When the latter definition is radiologic literature4,89 to describe the space deep to the
used, the submandibular space is subdivided into a sublin- visceral layer of DCF encircling the pharyngeal constric-
gual space superior to the mylohyoid, a submaxillary tor muscles between the skull base and cricoid cartilage;
space inferior and lateral to the mylohyoid, and a sub- nasopharyngeal, oropharyngeal, and hypopharyngeal divi-
mental space centrally.2,3 sions are reported.89 The pharyngeal mucosa represents
Several cadaver dissection studies, some of which have the deepest limit of this space.4,39,50,76,89 The pharyngeal
incorporated the injection of colored gelatin, have shown mucosal space is not the same as the ‘‘peritonsillar
free communication between the submandibular and para- space,’’ which has been described in surgical texts
pharyngeal spaces.1,19,43 However, other dissection stud- because this is the potential space between the capsule of
ies78 and clinical and radiologic observations do not the palatine tonsil and the superior constrictor and palatal
support such a communication.69 muscles.2,19,86,90 Nevertheless, the peritonsillar space lies
within the pharyngeal mucosal space.
Cervical fascial ‘‘spaces’’
Retropharyngeal and danger spaces. Building on earlier
The cervical fascial ‘‘spaces’’ include the historical studies,11,38,47,54 Grodinsky and Holyoke1 described 2
‘‘deep spaces’’ (parapharyngeal, retropharyngeal, danger, spaces bounded by visceral fascia anteriorly, prevertebral
prevertebral, and visceral spaces) as well as the more fascia posteriorly, and the alar fascia in between; these
recently defined pharyngeal mucosal and anterior and have been reaffirmed in modern studies48 and become
posterior cervical spaces. known as the retropharyngeal space (anterior) and the
danger space (posterior).1 The retropharyngeal space con-
Parapharyngeal space. A host of synonyms have been tains lymph nodes, whereas the danger space has no spe-
used for this space. It is commonly described as an cific contents.48 This division into 2 ‘‘spaces’’ is
inverted pyramid, cone, funnel, or triangle with the skull reinforced in the radiologic literature,4,79,82,91 but some
base superiorly and the greater cornu of the hyoid bone authors either do not describe a ‘‘danger space’’43,45,52,69
or mandible inferiorly,1,2,20,38,78,79 although this concept or consider the retropharyngeal and danger spaces as a
has been challenged.80 Laterally, it is bordered by the single functional space.4
medial pterygoid muscle and parotid gland, posteriorly by Craniad to the hyoid, the retropharyngeal space is
the prevertebral muscles or carotid sheath (depending on stated to either communicate freely with the parapharyng-
the definition), and medially by the visceral fascia cover- eal space1,20,38,47 or be limited by the lateral extent of the
ing the pharyngeal muscles.1,4,18,78,81 Some authors subdi- pharynx.11,37,39,78 Radiologic studies have reported no
vide the space into the anterior (prestyloid) and posterior communication with the parapharyngeal space in gen-
(poststyloid) compartments.41,80,82 This subdivision and eral,82 or with its ‘‘prestyloid’’92 or ‘‘poststyloid’’3 subdi-
the communications between this space and adjacent visions. Inferior to the hyoid, the retropharyngeal space is
compartments are controversial. stated to extend anterolaterally around the viscera.1 It has
Considering the first of these controversies, numerous also been suggested that it communicates with the vis-
structures have been suggested to subdivide the para- ceral space3,11,19,85 between the level of the thyroid carti-
pharyngeal space: the styloid muscles and posterior lage and inferior thyroid artery.3,79 The inferior limit of
belly of digastric (the so-called ‘‘styloid dia- the retropharyngeal space is variably described as lying

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TABLE 2. Cranial ‘‘spaces’’ and their contents.

Previous terms, with subdivisions Contents Suggested term

Parotid space Parotid gland, retromandibular vein, facial nerve, Parotid compartment
external carotid artery, lymph nodes
Masticator space, buccomasseteric Mandible (or just the alveolar ridge), masseter, Masticator compartment
region medial and lateral pterygoid muscles,
Suprazygomatic mandibular division of trigeminal
Infratemporal nerve
Nasopharyngeal Extension of buccal fat
Retrozygomatic
Superficial and deep temporal spaces Superficial: superficial temporal vessels and
branches of the auriculotemporal and facial
nerves, temporoparietal fat pad
Buccal space Buccal fat pad, parotid duct
Submandibular space Hypoglossal nerve, lingual nerve, submandibular Submandibular compartment
Submaxillary and sublingual glands, submandibular duct, lymph nodes
Sublingual
Submental

between the sixth cervical (C6) and fourth thoracic verte- not usually considered in the clinical literature on deep
brae (T4),1,3,45 at T1 to T2,2,17,62,93 T3,50 T2 to T6,94 or neck infections.2,20 The real clinical utility of these spaces
in the ‘‘upper mediastinum.’’4,95 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
Prevertebral or perivertebral space. The ‘‘prevertebral relations.3,98–100
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 Visceral space. Much of the confusion about this ‘‘space’’
to the coccyx.1,2,19,48 An alternative definition is a rec- stems from the variable nomenclature applied to the
tangular space between the MLDCF anteriorly and the MLDCF (see above). Thus, the visceral space has been
DLDCF posteriorly, extending to the mediastinum (ie, described as a potential space between the trachea, esopha-
the equivalent of the retropharyngeal space described gus, and thyroid, and their surrounding visceral fascia1 or,
above).11,37,38,85 Others describe a ‘‘periverte- alternatively, is seen as part of a larger space that includes
bral’’45,52,53 or ‘‘prevertebral’’41,94 space enclosed by the carotid sheath.47,85 Some authors have divided the vis-
fascia extending round to the spinous processes posteri- ceral space into anterior and posterior components,2,19 but
orly; this space has been divided into anterior or ‘‘pre- there is no convincing anatomic evidence to support this.
vertebral’’ and posterior or ‘‘paraspinal’’ portions by The space is reported to extend caudally as far as the tra-
fascial attachments to the transverse processes of the cheal bifurcation and/or arch of the aorta.1,2,11,19,47 The
cervical vertebrae.50,95 In these schemes, the preverte- radiologic literature more simply refers to a ‘‘visceral
bral space is stated to extend down to T3,4 the pericar- space’’ containing the larynx/trachea, pharynx/esophagus,
dium,41 or the coccyx.52,95 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
Anterior and posterior cervical spaces. The radiologic litera- and there is confusion about whether it communicates
ture refers to ‘‘spaces’’ in the regions occupied by the directly with the retropharyngeal space.
anterior and posterior triangles of the neck.8,96,97 A ‘‘pos-
terior cervical space’’ is described between the DLDCF
covering the scalene muscles and the Recommendations on compartments
sternocleidomastoid–trapezius fascia; it is limited antero- The concept of ‘‘spaces’’ assists with differential diag-
medially by the carotid sheath. The posterior cervical nosis, understanding the spread of disease, and clinical
space theoretically communicates with the axilla but management, including surgical access. However, the
spread of infection between these sites is uncommon.1 term ‘‘compartment’’ is more appropriate than ‘‘space’’
Anterior to the sternocleidomastoid is a separate smaller as no part of the head or neck is ‘‘free, available, or
fat-filled ‘‘anterior cervical space,’’ lying between the unoccupied.’’60 Compartments may be bounded by bone
superficial and middle layers of DCF, and extending from and/or muscle, as well as fascia, and individual compart-
the hyoid bone to the clavicles.93,97 Parker et al97 ments may intercommunicate. The trend to subdivide
described a communication between this space and the these compartments into smaller and smaller regions
submandibular space, despite the presence of a firm fas- should be resisted because this becomes progressively
cial attachment of the SLDCF to the hyoid.2,19 Infections less meaningful to clinical practice.
in the anterior and posterior cervical spaces tend to be The following compartments, summarized in Tables 2
localized or track toward the skin46,93 and therefore are and 3, are suggested.

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TABLE 3. Cervical compartments and their contents.

Previous terms, with subdivisions Contents Suggested term

Parapharyngeal space, paranasopharyngeal, Fat, tonsillar vessels, Parapharyngeal compartment


lateral pharyngeal, peripharyngeal, ascending palatine artery
pharyngomaxillary, pterygopharyngomaxillary, ICA, IJV, cranial nerves IX, X, XI Carotid compartment
pterygopharygneal, and XII, sympathetic plexus, and lymph nodes
pterygomandibular, pharyngomasticatory,
and lateral pharyngeal cleft
Prestyloid/anterior/anterolateral
Poststyloid/retrostyloid/posterior/posteromedial
Carotid space, carotid sheath, vascular space ICA, IJV, cranial nerve X, sympathetic
plexus, and lymph nodes
Retropharyngeal space Fat, lymph nodes (suprahyoid only) Retropharyngeal compartment
Danger space No contents
Perivertebral space, paravertebral space, Prevertebral muscles Prevertebral compartment
perivertebral space
Prevertebral space Paraspinal muscles, phrenic nerve, Perivertebral compartment
Paravertebral, perivertebral, paraspinal and cervical nerve roots
Visceral space, pretracheal space, anterior Pharynx, larynx, trachea, esophagus, Visceral compartment
visceral space, previsceral space thyroid gland (1/2 parathyroid glands)
Anterior cervical space Lymph nodes Levels 1 to 6
Posterior cervical space Lymph nodes, cranial nerve XI,
and cervical plexus

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 parapharyngeal compartments. The terms ‘‘prestyloid’’
this compartment for radiologic assessment. Surgery tends and ‘‘poststyloid,’’ although useful for traditional surgi-
to center around facial nerve preservation but fascial cal approaches to the parapharyngeal compartment, are
arrangements are useful in analyzing disease spread, par- not anatomically accurate and should be abandoned. The
ticularly in relation to the deep lobe of the parotid and current literature does not permit reliable conclusions
the parapharyngeal space. about the fascial arrangements and connections related
to the parapharyngeal compartment; in particular, the
Masticator compartment. This compartment is bound by relationship between the styloid muscles and the phar-
the masticator fascia. There is no clear clinical benefit yngotympanic tube within the compartment is poorly
from subdividing the compartment into temporal, infratem- defined.
poral, or retrozygomatic portions, as these are continuous
and inconsistently applied. The term ‘‘infratemporal fossa’’ Retropharyngeal compartment. Contemporary cross-
is best avoided when describing fascial compartments. sectional imaging cannot reliably distinguish the fascial
Although the buccal region houses a subdivision of the layer between the retropharyngeal space and the danger
masticator compartment bordered laterally by subcutaneous space. Clinically, treatment decisions on infections in this
tissue, medially by visceral fascia covering buccinator, and region are based on physical findings and response to
posteriorly by masticator fascia covering the masseter mus- antibiotics rather than whether the infection is in one
cle, there is no obvious advantage from labeling this as a ‘‘space’’ or the other. Therefore, it is more useful to con-
separate ‘‘buccal compartment’’ because it is in continuity sider a single retropharyngeal compartment. Further
with the masticator compartment and can be localized clin- investigations are needed to define the lateral and inferior
ically by reference to the buccal fat pad. limits of this compartment.

Submandibular compartment. This comprises the potential Prevertebral and perivertebral compartments. The former is
‘‘space’’ craniad and caudad to the mylohyoid muscle situated anterior to the cervical vertebral bodies and trans-
bound inferolaterally by the fascia of the submandibular verse processes and bound anteriorly by prevertebral fas-
compartment as it passes between the mandible and hyoid. cia. The latter is located posterior to the transverse
There is no discrete sublingual space. We recommend that processes of the cervical vertebrae and enclosed by peri-
this potential space is known as the submandibular com- vertebral fascia.
partment, with ‘‘floor of mouth’’ (as advised by the Ameri-
can Joint Committee on Cancer)99 being used to describe Visceral compartment. The precise fascial arrangement of
the ‘‘sublingual region’’ craniad to the mylohyoid. this compartment is not well understood and may vary
between individuals. Broadening the definition of the vis-
Parapharyngeal and carotid compartments. In the supra- ceral compartment to the region encompassed by the vis-
hyoid region of the neck, there are distinct carotid and ceral fascia seems appropriate. Whether it is in continuity

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FIGURE 1. (A–D) The layers of cervical fascia. (A) Subcutaneous tissue. (B) Masticator fascia, submandibular fascia, and sternocleidomastoid-
trapezius 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. for radiologic diagnosis. Pathology within the ‘‘pharyn-
Functionally, the visceral compartment is concerned with geal mucosal space’’ is actually within the pharyngeal
the airway, deglutition, and endocrine functions. The submucosa. When describing lymph nodes during the
terms ‘‘pretracheal,’’ ‘‘previsceral,’’ and ‘‘anterior vis- staging of malignant disease, levels I to VI as contained
ceral’’ should no longer be used. described by the Union for International Cancer Control
Adopting this scheme would allow consideration of a staging system99,100 are appropriate descriptors.
‘‘strap muscle compartment’’ and a ‘‘sternocleidomastoid-
trapezius compartment’’ because these are functional units
bound by fascia. However, recognition of these compart- CONCLUSIONS
ments has limited clinical utility. This review of anatomic and radiologic literature demon-
The ‘‘pharyngeal mucosal space’’ and ‘‘anterior and strates the confusion that exists about fascial layers and
posterior cervical spaces’’ are not precise anatomic com- ‘‘spaces’’ in the head and neck. Controversy surrounds the
partments and these terms are not currently used by sur- nomenclature, boundaries, and communications and further
geons. They have been introduced in the last few decades research is required to clarify the anatomy of some regions.

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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 dem-
onstrating 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 evidence-based anatomic findings should enhance under-
confusing descriptors such as ‘‘superficial layer of deep’’ standing of the neck and facilitate clearer interdiscipli-
creates a less ambiguous classification. Thus, the ‘‘super- nary communication.
ficial cervical fascia’’ should be referred to as ‘‘subcuta-
neous 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 compart-
ments in our scheme are identical to standard descrip-
tions, others are different and offer a more rational
approach to classification. The ‘‘submandibular compart-
ment’’ is a midline region bound superiorly by the tongue
and oral mucosa and inferiorly by the submandibular fas-
cia; 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 FIGURE 3. A. Cervical fascial layers and associated compart-
regions of the neck become better understood and ana- ments. B. Comparable axial MRI at the level of the thyroid
tomic and radiologic interpretations more congruent. Our isthmus.
proposal for a common language underpinned by

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