Supra- and infrahyoid neck continuation:

Anatomy of the oral cavity, pharynx,

continuity w suprahyoid neck : Carotid space
larynx and infrahyoid neck Retropharyngeal & danger space
Perivertebral (prevertebral, paraspinal)
Posterior cervical space

ECNR Dubrovnik 22.10. 2018

Bernhard Schuknecht
Medical Radiological Institutes Zurich
Switzerland
bschuknecht@mri-roentgen.ch
Infrahyoid only: Visceral space suprahyoid pharyngeal mucosal
Harnsberger ED. Diagnostic Imaging Head and neck 2nd edition Amirsys 2011
Anterior cervical space

Order of „business“ Infrahyoid level

Visceral space
= unpaired infrahyoid space
Anatomy and imaging issues
middle layer of deep cervical fascia
The space based approach spatial relationship
• Oral cavity retropharyngeal space
• Hypopharynx carotid space
anterior cervical space
• Larynx contents:
• Thyroid/ parathyroid gland larynx, hypopharynx
trachea, esophagus
thyroid, parathyroid- thymus
recurrent laryngeal nerve, paratracheal LN

How to approach neck lesions? LN level-classification in the neck

space based approach
Level I: superior to hyoid
Deep cervical fascia IA: submental, IB: submandibular
ĺsuperficial
ĺPLGGOH Level II: internal jugular -superior to hyoid
ĺdeep layer
IIA: anteror to SCM, IIB: medial to SCM

Ÿ separate spaces: suprahyoid Level III: int. jugular (inferior hyoid-inf. cricoid)
infrahyoid midthird vascular chain – SCM

Level IV: internal jug- inf cricoid- supraclavicular

lower vascular chain – SCM

Level V: posterior cervical space – supraclavicular

VA : above inf. cricoid level VB: below inf. cricoid

Level VI: prelaryngeal:

hyoid- jugulum

+ retropharyngeal, parotid, facial LN Level: VII: jugulum -aortic arch

upper mediastinum
Fig.Harnsberger Ed. Diagnostic Imaging Head and neck 2nd ed. I1 4,6; Amirsys 2011
 Sublingual & submandibular space:
Oropharynx content
squamous epithelium within the oropharynx derives from endoderm Sublingual space: not fascia lined
ĺSURSHQVLW\IRUGHYHORSPHQWRISRRUO\GLIIHUHQWLDWHGDJJUHVVLYHFDCV Sublingual gland, + minor salivary glands
submandibular, sublingual duct
Subsites lingual, glossopharyngeal, hypoglossal n.
• post. 1/3 of tongue,
• lingual tonsils,
Submandibular space : fascia lined
• palatine tonsils, Submandibular gland superficial lobe
• soft palate, (deep lobe = partly within SLS)
Facial artery, vein, digastric muscle (ant. belly)
• post. pharyngeal wall
LN: submental IA, submandibular IB
from Harnsberger Diagnostic Imaging Head and Neck, Amirsys 2004
Both spaces : extend from side to side

Oral cavity deep lobe submandibular &

sublingual spaces
squamous epithelium of the oral cavity derived from ectoderm
ĺWHQGVWRJLYHULVHWRPRUHGLIIHUHQWLDWHGOHVLRQV Sm gland: Superficial lobe in Sm space
deep lobe = partly within SLS
Subsites
sl+ sm VSDFHļabove midline
• lips,
sm VSDFHļparapharyngeal space
• 2/3 of the tongue,
superficial lobe
• buccal mucosa,
• gingiva,
• retromolar trigone,
• hard palate,
• floor of the mouth
Oropharynx + oral cavity cancer : incidence 8.5 : 100000
oral cavity to oropharynx 2:1
LQFLGHQFHWUHQGFDQFHURIRUDOFDYLW\ĻRURSKDU\Q[Ĺ

Tongue muscles Anatomic variations

Intrinsic: slong., ilong., transverse, vertical Unilateral agenesis of sm gland Staphne cyst
Extrinsic: genioglossus 1, hyoglossus 2,
styloglossus 3, palatoglossus 4

1 2

3
Herniation of sl gand
4

Root of tongue Floor of mouth

Geniohyoid-genioglossus complex and lingual septum
 Oral cavity neoplasms Anatomic division of the pharynx:
oral tongue ca
naso-, oro-, and hypopharynx
nasopharynx
skull base
Ÿ soft palate
oral tongue mucoepidermoid ca
oropharynx
soft palate
Ÿ pharyngo-epiglottic fold
floor of the mouth ca

hypopharynx
Ÿ cricopharyngeus m.
retreomolar adenoidcystic ca lateral
buccal mucosa ca
squamous cell neoplasms glandular neoplasms

Oral cavity congenital lesions Hypopharynx subsites:

piriform sinus,
postcricoid region,
• Vascular malformations: venous, lymphatic, mixed
posterior wall
• Germ cell tumours: epi-, dermoid, teratoma
dermoid, epidermoid,

venous / lymphatic vascular malformation • aryepiglottic fold anteromedially

• thyroid cartilage laterally

• paraglottic space anteriorly

• hypopharynx esoph. junction

Ÿ@ level of inf. cricoid lamina

Hypopharynx subsites:
Anatomical subdivision of the pharynx: piriform sinus,
naso-, oro-, and hypopharynx postcricoid region,
posterior wall
nasopharynx
Skull base
Ÿ Soft palate • aryepiglottic fold anteromedially

oropharynx • thyroid cartilage laterally

soft palate
Ÿ pharyngo-epiglottic fold • paraglottic space

hypopharynx • hypopharynx esophagus junction

Ÿ cricopharyngeus m.
pa Ÿ @ level of inf. cricoid lamina
Sobotta Becher 2nd ed. U&S 1972
 Glottis and subglottis
Anatomic subdivision of the larynx derived from tracheo-bronchial bud
sparse lymphatic drainage !
Glottis level:
Vocal cord = medial fibres of thyroarytenoid m.
anterior œ posterior commissure
+ 5mm below
Subglottis : mucosal surface close to cricoid
supraglottis Hyoid
conus elasticus fibroelastic membrane
5
betw. vocal lig. - cricoid cartilage
5 LN prelaryngeal = Delphian lymph node (s) (VI)
Thyroid c Level VI
glottis
subglottis
Cricoid c

M arytenoideus transversus + obliquus

Supraglottis Glottis-level
derived from buccopharyngeal anlage How to identify ?
Ÿ rich lymphatic drainage !

laryngeal vestibule thyroid c

epiglottis arytenoid c

cricoid c
pre-epiglottic fat

false vocal cords

ventriculus laryngis

paraglottic space

arytenoid cartilage

3 levels !

Larynx
false vocal cord
plica vestibularis

epiglottis

pre-epiglottic fat
cricoid c

false vocal cords arytenoid c.

true vocal cord
laryngeal ventricle vocal ligament
= glottis + 5mm

arytenoid cartilage

true vocal cord thyroid c

false cord
arytenoid c cricoid c.
paraglottic space true cord subglottis
cricoid c conus elasticus

cricoid cartilage
 Embryology: thyroid- parathyroid Thyroid/visceral space anatomy

• Thyroid lobes
and superior parathyroid
Ÿ 4th branchial pouch

• Isthmus thyroid
and inferior parathyroid
Ÿ 3rd branchial pouch
Inferior parathyroid (35% ectopic
hyoid, carotid, intrathyroid, mediastinal)
longer course of 3rd branchial pouch

VIBE Gd

Embryology Thyroid anatomic variation:

• Thyroid descent via thyroglossal duct Zuckerkandl tubercle
Posterior view: two different cases
from foramen cecum suprahoid midline
infrahyoid off midline to visceral space
• thyroglossal duct involutes at 5-6 gest. weeks
Thyroglossal duct cyst: 25% suprahyoid,
50% level of hyoid,
25% infrahyoid Black dots = parathyroid glands

Posterior thyroid tubercle “ Zuckerkandl tubercle”

• surgical landmark (proximity to recurrent laryngeal nerve)
• extension of thyroid to tracheo-esophageal sulcus in 87%,
• nodular configuration of ZT in 42.1% of patients.
• DD: Parathyroid adenoma

Lee TC et al. Zuckerkandl Tubercle of the Thyroid: A Common Imaging Finding That May Mimic Pathology.
Lingual thyroid
Thyroglossal duct cyst AJNR 2012 33: 1134-1138

Thyroglossal duct cyst Parathyroid gland anatomy

fistula continuation o thyroid isthmus

Dynamic CT Dynamic MR
VIBE Gd
Parathyroid adenoma
Adenoma > 5mm (10-30mm),
MR Imaging protocol Ÿ neck
CT Upper: posterior to upper midpole Coverage: orbital roof - below aortic arch
Lower: 65% lateral/posterior to lower pole
• sagittal T2 TSE 3 mm
20 % ectopic (intrathyroid, carotid, mediastinum..)
2-3% multiple
• coronal STIR 4 mm
<1% parathyroid carcinoma • axial T2 TSE fs Dixon 3 mm
Twist dynamic
Tc 99m sestamibi: early + delayed focal enhancement • axial T1 TSE localized 3 mm
Cholin PET: under investigation
US: homogenous, well defined hypoechoic, hypervascular
• axial DWI b 0, b 800-1000; ADC 5mm
Dynamic CT/ and – dyn. MR: early enhancement ! • axial VIBE Dixon Gd 3D 0.9 mm
Dynamic ceCT or ceMR arterial phase!! (T1 TSE Gd fs Dixon, T2 Space 0.8-1.0mm)

Specialized examination CT Imaging protocol neck

Dynamic ceMR sequence (10s intervall) MDCT (64/128)

Coverage Orbital roof – below aortic arch

• Collimation : 0.6mm
• Table feed per rot : pitch 1.0
• Rot. time, duration : 0.3s /16s
• Reconstruction slice: thickness/ increm. 1.0/0.7 mm, Fov 180
• MPR 3mm contig. : W/C soft tissue 270 -300/100
baseline 10s 20s 60s
W/C HR bone 2mm 3200/700(1700/600 cartilage)
Work in progress: improved detection of parathyroid adenoma (?) • 80ml nonionic contrast + 20ml saline 2ml/s; => 50s delay

- thank you

bschuknecht@mri-roentgen.ch